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UNITED STATES OF AMERICA. 



CLINICAL THERAPEUTICS. 



LECTURES IN PRACTICAL MEDICINE, DELIVERED IN THE HOSPITAL ST. 
ANTOINE, PARIS, FRANCE. 



PROFESSOR DUJARDIN-BEAUMETZ, 

PHYSICIAN TO THE COCHIN HOSPITAL, MEMBER OF THE ACADEMY OF MEDICINE 
AND OF THE COUNCIL OF HYGIENE AND SALUBRITY OF THE SEINE. 



THE TREATMENT OE NERVOUS DISEASES; OE 
GENERAL DISEASES; AND OE FEVERS. 



■»./ 




Translated by .E. P. HURD, M. D., 

Member of the Massachusetts Medical Society, Vice-President of the Essex North Medical Society; one of 
the Physicians to the Anna Jaques Hospital, Newburyport, Mass. 



DETROIT, MICH. 

GEORGE S. DAVIS 

1885. 







Copyrighted by 
GEORGE S. DAVIS, DETROIT, MICH. 

1885. 



AUTHOR'S PREFACE. 



This work, which my friend, Dr. Hurd, has so satisfactorily translated, and which Mr. 
George S. Davis (who has done much — in my estimation — to advance the cause of progres- 
sive therapeutics) now publishes, will, I hope, be found useful to American practitioners. 

The success which has attended the publication of these lectures in France, where the 
work, before its completion, had gone through four editions, and in foreign countries, where 
it has been successively translated into Spanish, by Dr. Reboles y Campos, of Madrid; 
into Italian, by Dr. Cozzolino, of Naples; into Greek, by Dr. Kyriazides — a translation into 
Russian is also in progress — shows the great interest which physicians of all lands are to- 
day manifesting in therapeutic advance. 

It has been my object to furnish a ready help to the busy practitioner, and especially, 
to young physicians commencing practice, by showing them how best to treat diseases, and 
by removing obstacles from their way. 

To attain this end, I have drawn largely from the published labors of all countries, for 
science is cosmopolitan, having no boundary lines. 

In order to judge of the value of the various medications in usage, one should always 
ask first, what are the clinical results ? It is to this test that I have endeavored, impartially, 
to make appeal. My hospital opportunities have been great, and I have sought to obtain 
from them the utmost possible returns. 

Therapeutics, which, as a branch of medicine, has been so much neglected, I may 
almost say despised, since the commencement of this century, is to-day claiming its rights 
and its pre-eminent position being first in the hierarchy of medical sciences, and all 
the other studies being subservient to it. On all sides we now see tokens of splendid 
promise. Yesterday the leading interest was in resorcin, kairine, antipyrine, and other 
new antithermic medicaments, which enable us to be masters of the temperature; to-day it 
is in cocaine, with its marvellous local anaesthetizing properties; to-morrow, or in the 
near future, it will be in the vegetal world, better known and applied to therapeutics, or in 
chemistry, by synthesis discovering new medicines, or in the protective benefits of at- 
tenuated virus creating media refractory to infectious diseases. 

The United States has not been behind in beneficent medical work; we owe already 
to this country of enterprise and of progress, the greatest therapeutical discovery of our 
age, and of ages to come: surgical anaesthesia. 

Therefore, it is with extreme satisfaction that I have accepted the proposition of Dr. 
Hurd, and I take this occasion to thank him for the assiduity, pains-taking, and accuracy 
with which he has translated these lectures, which I hope will receive a favorable reception 
from my American confreres, with whom the entire body of French physicians has such 
hearty sympathy — sympathy created by the bonds of affection which have so long united 
France to the great Republic of the United States. 

Paris, August, 1885. Dujardin-Beaumetz. 



TRANSLATOR'S PREFACE. 



Doctor Dujardin-Beaumetz, the author of this work, was born at Barcellona, in Spain, 
on the twenty-eighth day of November, 1833. He is the son of a farmer who is now living 
on an estate near Vendome, in the department of Loir and Cher. His father's family, by 
name Dujardin, was originally from a town of the north of France, which bore the name 
Beaumetz; for a long time the surname of the family was written: Dujardin de Beaumetz; 
the prefix, de,. was eventually dropped, and the cognomen was henceforth written as at 
present. 

Dr. Dujardin-Beaumetz's classical studies were performed at the College (Lycee) St. 
Louis, and the College Soutane, Paris. His first intention was to devote himself to agricul- 
ture, but he soon abandoned this purpose, and took up the study of medicine. In this he 
soon became remarkably proficient, and graduated at the Ecole de Medecine, in 1862. With 
a strong and growing passion for hospital work, he was successively, externe, then interne, 
under Velpeau, and chef de clinique under Behier. He has been three times Laureat of 
the Faculty, then Laureat of the Hospitals, and finally, Laureat of the Institute, obtaining 
the prize Montyon, for his Researches on the Alcohols. 

For his gallant conduct during the siege of Paris, in caring for the wounded soldiers 
under the fire of the enemy, at the battle of Montretout, he was honored with the title of 
Chevalier of the Legion of Honor. He has been physician in chief to two large hospitals, 
the hopital Saint Antoine, and the hopital Cochin; he is at present connected with this 
latter hospital, in which, besides having the general medical supervision of that vast eleemos- 
ynary institution, he has charge of a fine laboratory for chemical and physiological experi- 
mentation. Dr. Beaumetz has also a large private practice, is member of numerous learned 
societies (Academy of Medicine, Societe des Hopitaux, Societe de Therapeutique, etc.), which 
demand much of his time; he is also editor-in-chief (secretaire de la redaction) of the Bulletin 
general de therapeutique, one of the oldest and most influential of the French medical journals, 
an office which he has held since 1874. 

Dr. Dujardin-Beaumetz has been already a voluminous writer. Among his published 
works we cite the following: 

1. On Locomotor Ataxia. — An inaugural thesis of 75 pages. It comprises reports of 
ten cases which came under the observation of the writer. 

2. Etude sur le Cholera. — This is a study of the cholera epidemic of 1865 and 1866. 

3. Ocular Troubles in Diseases of the Spinal Cord. — In this memoir are contained the 
greater number of facts which have been observed of eye troubles in the course of diseases of 
the spine, and an attempt is made to point out the ties which unite these visual disorders 
with the medullary alterations. 

4. On Acute Myelitis. — This is the author's these d' agregation, and is a volume of 162 
pages. It is a complete history of acute myelitis. This is an exhaustive treatise of the 
subject, and in France, has become classical. 

5. Researches on Gelsemium, 1878. — In this thesis the author studies the physiological 
and therapeutical properties of gelsemium, showing, first of all, the toxic effects of this sub- 
stance on animals, then its therapeutic effects in neuralgia, and especially in facial neuralgia. 
(Written in collaboration with Dr. Emery.) 

6. Researches on Nutritive Lavements, 1879. — In this memoir the author combats the 
opinion that alimentary lavements have a real nutritive value. He shows that the rectum, 
being destitute of villosities, can absorb only liquids, and that the penetration of peptonized 
substances thereby is difficult, if not impossible. In the case of lavements of milk or 



VI TRANSLATOR S PREFACE. 

broth, only the water and the salts are absorbed, while the fatty and albuminoid matters can 
not enter the economy through this channel, and even in employing the method of Leube, 
the peptones cannot be utilized by the lectum. He has supported this view by personal 
clinical researches, which showed that in persons affected with stenosis of the oesophagus or 
pylorus, alimentary lavements failed utterly to increase the weight and temperature, or the 
quantity of urea excreted in twenty-four hours. 

7. On the Treatment of Aneurisms of the Aorta by Electro-puncture, 1878. — In this 
treatise the writer sums up the cases of acute aneurism occurring in his hospital service, 
which he has treated by electro-puncture, and shows that this method, applied to the treat- 
ment of aneurisms, is a simple and relatively safe operation, and one of the most efficacious 
and rational means of cure. 

8. Researches on Pelletierine, 1878. — This is a communication published in the Bulletins 
et Memoires de la Societe de therapeutique, in which the results of the author's trials in the 
hopital St. Antoine, with this new taenicide, were recorded. He shows it to be one of the 
best, if not the best remedy for tape-worm in possession of the medical profession. 

9. Experi?nenial Researches on the Toxic Power of the Alcohols, Paris, 1879. — This 
work, which is a stout octavo volume of over 300 pages, fills a lacuna previously existing in 
our knowledge respecting the physiological and toxic effects of the divers alcohols. Over 
three hundred experiments were made to ascertain the relative toxicity of ethyl, methyl, 
amyl, and other spirits which, more or less, impregnate the various intoxicants in common 
use, being naturally found there, or artificially added, and which are the cause of certain 
well-known excitant effects on the animal or human organism. 

The animals on which these experiments were performed were dogs and swine. 
Dujardin-Beaumetz was assisted in these experiments by Dr. Audige. They employed 
chiefly the hypodermic method, and called minimum toxic dose that quantity of pure alcohol 
which by kilogramme of the weight of the body of the animal, is necessary to cause death 
in the space of twenty-four to thirty-six hours, with gradual and permanent fall of the 
temperature. By pure alcohol is understood alcohol of ioo° in the scale of Guy Lussac. 

The following conclusions result from these researches: 

The least toxic of the alcohols is the ethyl alcohol from vinous fermentation. The 
most toxic is the amyl alcohol (potato spirit, fusel oil). 

As for the toxic phenomena determined by the alcohols, they may be divided into three 
periods: A period of ebriety, or excitation, a period of resolution, and a period of collapse. 
These periods undergo modifications depending on (1) the nature of the alcohol employed; 
(2) the dose administered; (3) the resistance of the subject. 

With the al:ohols obtained by fermentation, the three periods of acute intoxication 
succeed each other in a regular order, bat in proportion as you depart from the ethyl series, 
their character is more accentuated, their evolution more rapid, and you see certain con- 
vulsive phenomena appear. 

With methyl alcohol (wood spirits) the period of excitation is more intense, resolution, 
collapsus, and the toxic symptoms which accompany them arrive more rapidly at their 
maximum, but, in case the dose is not sufficient to kill, the phenomena disappear more 
promptly. 

With cenanthylic and caprylic alcohols the periods of intoxication do not present the 
same regularity, and convulsions occur. Glycerine causes an increase, rather than a fall of 
temperature. 

In the case of all animals which have died from acute poisoning by alcohol the 
necropsy discloses lesions of the respiratory and circulatory apparatus, of the nervous sys- 
tem and of the kidneys. As for the digestive apparatus, the lesions on the part of the gastric 
mucous membrane are inconspicuous when the alcohol is introduced by the hypodermic 
method, but when the poison is administered by mouth, the mucous membrane of the stom- 
ach is invariably found softened, and the more concentrated the alcohol, the greater the 
softening. The intestine undergoes the same alteration; it is found softened, and of a reddish 
black color; punctiform haemorrhages are produced, even when the alcohol is injected under 
the skin (elimination of alcohol by the intestinal glands). 



TRANSLATOR S PREFACE. VII 

The liver is more profoundly altered than any other gland. It is congested, softened 
and friable. The spleen is engorged with blood and softened. As for the respiratory and 
circulatory lesions, they are characterized by a profound alteration of the blood, which 
becomes dark, and forms in the heart clots in considerable quantity. The lungs are con- 
gested and contain apoplectic foci. The kidneys are injected and present hemorrhagic 
extravasations, especially when fusel oil (potato spirit) is used. 

Acute alcoholic poisoning in the human subject, is attended with similar symptoms, 
and presents similar post mortem lesions. 

io. Chronic Alcohol Poisoning. — Since the publication of the treatise above referred 
to, a little brochure has appeared, giving the results of a series of experiments by Dr. 
Dujardin-Beaumetz and his colleague, on chronic alcohol poisoning.* The subjects of these 
experiments were hogs, twenty of which were, during the space of two years, daily dosed 
with small quantities of the various alcohols in order to determine the symptomatological 
and pathological results. 

It was in 1879 that Dujardin-Beaumetz and Audige commenced in the abattoirs of 
Grenelle their researches on slow intoxication by the alcohols. They used, as before stated, 
hogs as the subjects of their experiments, giving these animals daily quantities of the differ- 
ent commercial alcohols, which varied from one gramme to three grammes by kilogramme 
of weight. When the quantity was exceeded of five grammes to the kilogramme, the animal 
emaciated rapidly, refused to eat, and soon died. 

Among the post mortem changes, the lesions of chronic gastritis were noted; also fatty 
changes in the kidneys. In the case of two of these animals, the necropsy revealed athero- 
matous degeneration of the aorta. In no instance was cirrhosis of the liver observed, or any 
of the chronic interstitial diseases. Beaumetz explains the absence of hepatic cirrhosis 
by the fact that the fibrous web-work of the hog's liver is thicker and more resisting than 
that of man, and that in consequence it is more difficult to choke out the glandular ele- 
ments. 

The most marked manifestation of chronic intoxication in these animals was a profound 
prolonged somnolence without any period of excitation. There was also a trembling and a 
weakness in the limbs. It is worthy of special note that the symptoms of intoxication were 
much less pronounced when ethyl alcohol was used, and that swine will support for a long 
time, apparently with impunity, moderate quantities, administered regularly every day, of 
pure spirits (wine, beer, rum, whiskey, etc.), containing only ethyl alcohol. 

In experiments undertaken to prove the combustion or noncombustion of alcohol 
in the economy, these physiologists were positive in having found aldehyde in the viscera 
of men and animals poisoned by ethyl alcohol, and had even obtained in one of their 
experimentations, the reduction on a mirror of silver nitrate which is one of the best 
tests of ethyl-aldehyde, but a more attentive examination of the facts has shown them 
that the aldehyde which they found may have come from its presence in the normal 
state in a great number of alcoholic liquors. Therefore, nothing definite has been 
determined by these experiments as to the formation of aldehyde out of alcohol in the 
economy. 

The conclusions which Dr. Dujardin-Beaumetz deduces from this interesting experi- 
mentation (see the entire treatise as reproduced by me in the Therapeutic Gazette for July 
and August, 1884), are as follows: 

" In fine, to complete the detail of experiments which have cost us so much in money, 
and about three years of careful observation, we observe: 

1. That the alcohols, administered in a slow and continuous manner, determine in the 
hog, at the end of a certain time, anatomical lesions, which consist in congestions and 
inflammations of the digestive tube, and of the liver, without at the same time attaining to 
that degree of interstitial hepatitis which is noted in hard drinkers in human kind; in con- 
gestion of the pulmonary parenchyma, which may end in apoplectic extravasations; in 



* Experimental Researches on Chronic Alcoholism, Paris, 1884. pp. 60. 



VIII TRANSLATOR S PREFACE. 

atheromatous degeneration of the large vessels, and especially the aorta, and finally, in 
sanguineous effusions into the substance of the muscles, and in the cellular tissue. 

2. That ( these lesions, inappreciable at the end of thirty months in cases where ethyl 
alcohol was given, and alcohols having other origin than vinous fermentation, but which 
had been thoroughly rectified, are very conspicuous in subjects to which have been admin- 
istered crude spirits, whether from beets, grain, or potatoes. 

3. That preparations of absinthe are especially baneful in their effects on the nervous 
system: 

These results, considering the time and pains we spent, may seem inconsiderable. We 
think, nevertheless, that they deserve to go on record, for they strikingly confirm our first 
experiments, and enable us to affirm that the disorders observed in man as the sequel of 
alcoholism, are really due to the slow and progressive absorption of the poison to which he 
surrenders himself every day. We hope, therefore, that these new experiments will find a 
welcome with all who are interested in this social question of the times." 

11. Dictionnaire de Therapeutique. — In 1882 Dr. Beaumetz planned a very extensive 
work, which is now about half completed. I refer to his Therapeutical Dictionary, which is 
being published in four large volumes, each volume comprising about a thousand pages. 
Here everything which is of recognized utility in the treatment of disease — medicines, 
hydrotherapy, electricity, aerotherapy, balneation, etc., comes up for exhaustive consideration. 
As an indication of the thoroughness of this work, I may mention that the one article 
Electricity covers 130 quarto pages, the article on Waters {eaux) 95 pages, that of Bacteria 35, 
that of Ergot 25 pages, etc. Dr. Beaumetz is assisted in this work by Drs. Debierre, Egasse, 
Hetel, Jaillet, Macquarie, and Bardet. 

12. Researches on phosphorus medication, 1868. — In these researches the author studies 
the phosphorus preparations, shows the inconveniences of the officinal preparations in com- 
mon use, and advises the solution of phosphorus in chloroform or ether; one of the best 
forms of administration is the phosphorated oil of Mehu's formula, which may be advan- 
tageously given in capsules, each capsule containing one milligramme of phosphorus. In 
the second part of this work he shows the advantages which may be derived from the internal 
administration of phosphorus in the medullary scleroses. 

13. Researches on carbazotate of ammonia, 1872. — The above is a valuable contribution 
to the study of a new antiperiodic medicament. 

14. Researches on subcutaneous injections, 1872. 

15. Researches on the action of iodine solutions on caoutchouc tubes, 1872. 

16. On the treatment of hydated cysts, 1872. 

17. Studies on the physiological and therapeutical action of the ammonia compounds, 1873. 

18. On the external applications of chloral and metachlural, 1873. 

19. On intravenous injections of water in the treatment of cholera, 1873. 

20. On the use of oatmeal in the alimentation of infancy, 1873. 

21. On the treatment of hepatic colic, 1873. 

22. A study of boldo, 1874. 

23. Researches on the action of ailantus gladulosa, 1874. 

24. A study of the therapeutical actions of apomorphia, 1874. 

25. A study of the action of the phosphates of lime, 1875. 

26. On the indications of the treatment of cerebral rheumatism by cold baths, 1875. 

27. On expectancy as a method of treatment in ncute rheumatism, 1875. 

28. A study of the ferruginous medication, 1876. 

29. A study of the physiological and therapeutical action of the salts of cicutine, 1 876. 

The foregoing sixteen treatises, which are merely mentioned by title, are communi- 
cations from the pen of Dr. Dujardin-Beaumetz which have appeared among the publica- 
tions of the various hospital, therapeutical and other learned societies prior to 1877. They 
are all based on original research, contain new facts, and constitute a valuable addition to 
medical literature. 



TRANSLATOR S PREFACE. IX 

30. On the preparations and uses of meat powder* 1882. 

31. On lavage and gavage of the stomach, f 1883. 

In these articles the various methods now in use for the treatment of chronic dis- 
orders of the nutrition are described. Especial emphasis is laid on the utility of washing 
out the stomach and forced feeding in certain morbid states of the stomach. The author 
gives a minute account, illustrated by figures, of the operative procedure, with the 
flexible syphon, employed by him, and the improvements which he has introduced into the 
new methods of "lavage" and "gavage." 

Those who are familiar with the medical literature of the last six or seven years 
know that great progress has been realized in this department of therapeutics. No one 
perhaps, has contributed more toward this advance than Dr. Dujardin-Beaumetz. 

32. Lecons de Clinigue Therapeutique, Paris, 1879-85. — This work, of which the present 
translation is the third and final volume, will probably for many years to come be considered 
as Dr. Dujardin-Beaumetz's most important work. 

The first volume comprises the therapeutics of diseases of the heart and digestive tube; 
the second, the treatment of diseases of the liver, kidneys and lungs. 

The first and second volumes have now gone through four editions, and the favor 
with which the work in its entirety has been received in France is something almost unpre- 
cedented. 

Dr. Lucien Deniau, a former pupil of the professor, now a practising physician in 
Paris, thus writes me with regard to these lectures on Clinical Therapeutics. 

"I learn with pleasure your intention to publish a translation of Dr. Dujardin- 
Beaumetz's work on Therapeutics. Ardent disciple of the celebrated professor, I had the good 
fortune to take part almost in the inception of this great undertaking, than which I have 
known none ever to be received with greater approbation by the Parisian medical public, 
not generally over prodigal with its favors. While a student, I was constantly in at- 
tendance on those public teachings, many of which you are about to incorporate in the 
book which Mr. Davis will have the honor to publish. The great amphitheatre of the St. 
Antoine hopital was ever crowded with an appreciative audience of under-graduates and 
practitioners of medicine, who came here to learn from the lips of a master what arms 
they might most successfully wield in the great warfare against disease and death. The 
favor with which students and physicians welcomed these first lessons on clinical thera- 
peutics has gone on increasing, and I may truly say to-day that in the amphitheatre of 
the Hopital Cochin, which the administration has built expressly for the clinical teaching 
of the professor, every 'conference' constitutes a veritable scientific festival." 

The lectures as originally delivered were oral (as I have been informed by the pro- 
fessor); they were afterwards written out, and the notes appended. The text is, in fact, 
largely the fruit of the notes, which have cost the writer infinite labor. The works con- 
sulted in their preparation comprehend, as may be seen from the bibliographical indica- 
tions, a wide range of medical literature. Possessed of a prodigious memory, Dr. 
Dujardin-Beaumetz has a happy faculty of gleaning from extensive fields the choicest 
wheat, and the substance of entire volumes is often comprised in a single lecture. The 
work is eminently practical and is designed to assist the physician in his daily duties; dis- 
eases are described as he is likely to meet them; and from the data furnished by etiology 
and pathology, therapeutical indications are derived. Clinical Therapeutics is really a 
treatise on practice in which everything is subordinated to therapeutics. Much that in 
ordinary text-books on materia medica and practice is rather embarrassing to the practi- 
tioner than helpful is here omitted, while the important data, set forth in strong light and 
grouped in a few masterly generalizations, indicate to him where he can be truly useful, 
where his intervention is demanded, as well as the limits of that intervention. It has 
been objected that Dr. Dujardin-Beaumetz, is too zealous for new remedies and new 
methods of treatment, but in reality he is eminently conservative as well as progressive. 



♦Bull. Gen. de therapeutique, T882. 
tlbid. 1884. 



X TRANSLATOR S PREFACE. 

While his motto is to "prove all things," he is equally characterized by a disposition 
to "hold fast to that which is good." As an illustration, I may only refer to his at- 
titude toward certain new remedies, such as convallaria, antipyrine, glonoine, salicylic 
acid and salicylate of soda, etc. He was among the first thoroughly to test these medi- 
caments in his hospital service where he has ever ample opportunities, and the judg- 
ment which he pronounced is the judgment which is sanctioned by the consensus of 
medical experience the world over. 

It may be said (and it has, in fact, often been said) that we have already too many 
medicaments, and that it would be well to learn more about, and make a better use of 
those really good medicines which our fathers used, and whose action in combating morbid 
phenomena is incontestable. This, to a certain extent is true; there is one extreme which 
should be avoided — the forsaking of the old paths where there is more or less of certainty 
for new paths which have hardly yet been traversed, and which may lead into pitfalls. 
There is also another extreme which is equally reprehensible : overweening confidence in 
the traditions and methods of the past, and satisfaction with things as they are; it is a 
spirit which is inimical to all progress. Better by far for the physician to have some high 
ideal before him, an ideal which constantly demands more light on diseases, and improve- 
ments in methods and medicinal agents; there is little in the present state of medicine which 
should inspire satisfaction, and everything to stimulate to advancement. That progress 
has been made, especially during the last decade, no well informed man can deny; few 
have contributed more toward these useful gains in the department of healing than the 
author of this work; that we are at the dawn of a more glorious era of scientific 
achievement in which the uncertainties of therapeutics shall no longer be the reproach of 
our noble profession, we may fervently hope. 

In the translation of this work I have had the constant co-operation and sympathy 
of the Paris author, for whose friendly services I shall ever be deeply grateful. 

Translator, 
Newburyport, Mass., June 6th, 1885. 



CONTENTS. 



CLINICAL THERAPEUTICS 



What is Meant by the Term Clinical Therapeutics — Clinical Medicine and Clinical 
Therapeutics — Utility of Therapeutics — Scepticism and Enthusiasm in Thera- 
peutics — Illusions in Therapeutics — Is Medicine an Art, or a Science ? — 
Empirical and Experimental Therapeutics — Polypharmacy in Therapeutics — 
The Treatment of Symptoms — Constancy in Therapeutics — Necessity of Cool 
Judgment in Therapeutics — Accumulation of Doses — The Art of Prescribing 
— The Par: of Hygiene in Tnerapeutics — The Part of Etiology in Thera- 
peutics. 



PAKT FIRST. 



THE NERVOUS SYSTEM FROM A THERAPEUTIC STAND- 
POINT 9 

Difficulty of the Study of the Therapeutics of Diseases of the Nervous System — 
Moral Therapeutics — Structure of the Nervous System — The Nerve Cell — 
The Nerve Tube — Chemical Composition of the Nervous System — Phos- 
phorus in the Nervous System — Action of Medicines on the Nervous System 
— Anaesthetics — The Direct Action of Anaesthetics on the Nervous Elements 
— The Action of Alcohol — Effect of Two Medicinal Substances on the Nerv- 
ous Elements — Resistance to the Action of Certain Medicaments on the 
Vaso-motors — Vaso-constrictor and Vaso-dilator Medicines — Action of Ergot 
— Action of Morphia — Spasmodic and Anti-spasmodic Medicaments — Role 
of the Nervous System on the Secretions — Secretory Medicaments — Antag- 
onism of Jaborandi and Atropine. 

HYDROTHERAPEUTICS 20 

History of Hydrotherapy — Priessnitz — Physiological Action of Cold — Reaction — 
Action of Hydrotherapy — Action on the Nervous System — Action on the Cir- 
culation — Action on Nutrition — Mode of Application of Cold Water — Douches 
— Pressure of the Water — Temperature of the Water — Alternating Douches — 
Duration of the Douche — Sudation before the Douche — Immersions — Affusions 
— Applications of Ice — Pulverizations of Ether. 

MEDICAL ELECTRICITY 28 

History — New Theory of Electricity — Intensity of the Current — Static and Dy- 
namic Electrical Apparatuses — Physical Phenomena of the Electric Current — 
Chemical Phenomena of the Electric Current — Physiological Action of 
Electricity — Action on the Muscular System — Electro- Capillary Phenomena — 
Action on the Nervous System — Action on the Circulation — Action on 
Nutrition — Technics. 



XII CONTENTS. 

TREATMENT OF NEURALGIA 50 

Definition — Pathogeny and Causes of Neuralgia — Influence of the Nervous System 

— Influence of the Circulation — Influence of Diseases of the Blood — 
Treatment of the Neuralgias — Symptom Treatment — Nervous Medieaments — 
Morphia — Atropine — Chloral — Chloroform — Injections of Chloroform — 
Aconite and Aconitine — Gelsemium and Gelsemine — Electricity — Hydrotherapy 
— Surgical Treatment — Neurotomy — Neurectomy — Nerve Stretching — Revuls- 
ive Medication — Cutaneous frictions — Vesicatories — Cauterization — Injections 
for Local Effect — Acupuncture — Reveilleur de la Vie — Aquapuncture — Galvano- 
Puncture — Empirical Medication — Phosphorus — Guarana — Sulphate of Copper 

— Pathogenic Medication — Essential Neuralgias — Bromide of Potassium — 
Neurites — Revulsion — Congestive Neuralgias — Aconite — Neuralgias by 
Anaemia — Morphia — Dyscrasic Neuralgias — Chlorosis — Arsenic — Intermittent 
Neuralgia — Quinine — Syphilitic Neuralgia — Arthritic, Dartrous Neuralgia — 
Treatment of Certain Varieties of Neuralgia — Neuralgia of the Foot — Sciatica — 
Uterine and Vesical Neuralgia — Ileo-Lumbar Neuralgia — Intercostal Neuralgia 
— Trifacial Neuralgia — Odontalgia — Tic Douleureux — Migraine. 



TREATMENT OF HYSTERIA 80 

Difficulty of the Subject — Vague Delimitation of Hysteria — Comprehends a Great 
Number of the Diseases of the Nervous System — Impossibility of Assuring 
a Therapeutic Result in Certain Cases of Hysteria — General Treatment of 
Hysteria — Hygienic Treatment — Education, Its Role as a Prophylactic — 
Influence of the Uterus in Hysteria — Influence of Continence — Of Marriage — 
Influence of the Husband — Kind of Life — Influence of Disappointments — 
Excitement — Alimentation — Medical Treatment — Antispasmodics — Valerian 
— Castor Assafetida — Bromides — Baths — Hydrotherapy — Means of Applica- 
tion—Mineral Waters— Electricity— Influence of Static Electricity— Galvanism, 
Metalloscopy and Metallotherapy — History — Burquism — .^Esthesiogenous Sub- 
stances—Results of Metallotherapy— Its Modes of Application— External and 
Internal Metallotherapy— Treatment of the Attack— Cold Water— Compres- 
sion of the Ovary — Mechanical Compression— Galvanism — Medicinal Inhala- 
tions—Nitrite of Amyl— Treatment of Certain Symptoms— Paralysis— Contrac- 
tures — Anaesthesia — Amaurosis — Gastric Hysteria — Anorexia — Vomiting — An- 
uria — Electricity — Ether Spray — "Gavage" — Conclusions. 



TREATMENT OF EPILEPSY 107 

Treatment of Epilepsy— Curability and Incurability— General Treatment— Patho- 
geny and Etiology — Experimental Epilepsy — Disease of the Spinal Cord, the 
Nerves, and the Brain— Causes— Therapeutics of Symptomatic Epilepsy— 
Antisyphilitic Treatment — Revulsion — Essential Epilepsy — Physiological Pa- 
thology—Treatment of Essential Epilepsy— Empirical Medication— Galium, 
Valerian, Hyoscyamus, Belladonna, Indian Hemp, Nitrate of Silver, Oxide of 
Zinc, Ammonio-sulphate of Copper, Bromide of Potassium— History— Physio- 
logical Action of the Bromide of Potassium — Employment of Bromide of 
Potassium in Epilepsy— Result of the Treatment— Rules of Administration— 
The Alkaline Bromides— Bromides of the Metals— Doses— Mode of Adminis- 
tration—Duration of Treatment— Curare, Cocculus Indicus and Picrotoxine— 
Treatment of the Attack — Hygienic Treatment. 



CONTENTS. XIII 

TREATMENT OF CHOREA 128 

Different Kinds of Chorea — Curability of Chorea — Pathogeny of Chorea — Divers 
Medications Proposed — Muscular Medicaments — Strychnine — Aniline — Eser- 
ine — Curare — Medullary Medicaments — Picrotoxine — Hyoscyamine — The 
Bromides — Electricity — Galvanic Baths — Ether Spray — Anaesthetic Medica- 
ments — Morphine — Chloral — Chloroform — Medicaments that Act on the 
General Condition — Tartar Emetic — Bloodletting — Hydrotherapy — Sulphur 
Baths — Gymnastics. 

TREATMENT OF MENINGITIS 141 

Varieties of Meningitis — Tuberculous Meningitis — Its Curability — March of Tuber- 
culous Meningitis — Symptoms — Prophylactic Treatment — Influence of Hered- 
ity — Hygienic Treatment — The General Treatment — Revulsion — Cold Appli- 
cations — Bloodletting — Internal Treatment — Calomel — Quinine — Calmatives 
— Butternut Leaves — Iodide of Potassium — Difficulties of Diagnosis — Acute 
Meningitis — Chronic Meningitis. 



TREATMENT OF APOPLEXY 154 

Apoplexy — Definition — Cause — Apoplexy by Rupture — Apoplexy by Anaemia — 
Apoplexy by Congestion — Treatment of Apoplexy by Haemorrhage — Treat- 
ment Before the Attack — Treatment of the Attack — Bloodletting — Its 
Role — Inefficacy of Bloodletting — Treatment After the Attack — Pharmaceu- 
tical Means — Arnica — Strychnine — Electricity — Treatment of Apoplexy by An- 
aemia — Before, During, After the Attack — Treatment of Apoplexy by Conges- 
tion — The Apoplectic Temperament — Pathogeny of Cerebral Hyperaemia — 
Hygienic Treatment — Bad Influence of the Alcohols — Obesity and Apoplexy — 
Utility of a Normal Functional Condition of the Digestive Tube — Constipa- 
tion — Purgatives — Aloes — Haemorrhoids in Apuplectic Patients — Diagnosis — 
Conclusions. 



TREATMENT OF CHRONIC MYELITES 166 

On Diseases of the Spinal Cord — Progress of Pathological Anatomy — The Differ- 
ent Inflammatory Processes — Myelites, Acute or Parenchymatous — Myelites, 
Sclerous and Interstitial — Their Varieties — General Treatment — Bloodletting, 
Local and General — Revulsion — Utility of Revulsion — Experimental Re- 
searches on Revulsion — Reflex Paraplegias from Cold — Hydro-therapy — Cold 
Douches and Warm Douches — Electricity — Ergot — Empirical Medication — 
Nitrate of Silver — Phosphorus — How to Give Phosphorus — Treatment of the 
Different Varieties of Myelitis — Treatment of the Hyperaemia — Influence of 
Decubitus — Treatment of Meningo-myelites — Treatment of the Consecutive 
Paraplegia — Electricity — Hydro-therapy — Thermal Treatment — Strychnine — 
Indications and Contra-indications — Treatment of Myelites by Compression — 
Anti-syphilitic Treatment — Treatment of Sclerosis of the Posterior Columns 
— Its Progressive March — Its Incurability — Bad Effects of Hydro-therapy — 
Thermal Treatment — Treatment of the Douleurs Fulgurantes — Injections of 
Morphia — Effect of Temperature — Nerve-stretching — Electricity — Treatment of 
the Atrophic Paralysis of Infancy — Electricity. 



XIV CONTENTS. 



PAET SECOND. 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. ... 191 

Composition of the Blood-*— The Plasma — Its Alkalinity, Its Composition — The 
Globules— The Red Globules— Haemoglobin— The White Globules— The Hae- 
matoblasts, Enumeration of the Globules — Its Importance Therapeutically — 
Divers Methods of Enumeration — Hayem's Method — Qualitative Value of the 
Globules — Chromometric Process — Action of Medicaments on the Globules — 
Passage of Medicaments into the Blood — The Blood as the Vehicle of Med- 
icaments — Modifications of Medicaments in the Blood — Direct Introduction 
of Medicaments into the Blood — Intra-venous Injections — Dangers of these 
Injections — Transfusion; History — Transfusion of Blood from the Animal to 
Man — Transfusion of Blood from Man to Man — Transfusion of Whole Blood, 
and Defibrinated Blood — Operative Procedure — Transfusion into the Arteries 
— Quantity of Blood Injected — Dangers of Transfusion — Results of Transfu- 
sion — Indications and Contra-indications — Injections of Blood into the Cellu- 
lar Tissue — Injections of Blood into the Peritoneum — Intravenous Injections 
of Milk — Its Dangers — Intravenous Injections of Water and of Saline Solu- 
tions. 

ON BLOODLETTING 210 

Bloodletting — History — Popularity and Decadence of Bloodletting — Divisions — 
Local Bleeding — General Bleeding — Arteriotomy — Phlebotomy — Manual Pro- 
cedure of Bleeding — Experimental Researches — On the Influence of General 
Bloodletting — Action on the Blood — Modifications of the Globules — Modifica- 
tions of the Serum — Influence on the Circulation— Modifications of the Pulse 
— Modifications in the Speed of the circulation — Modifications of the Mass of 
Blood— Modifications of the Blood Pressure — Influence on the Respiration — 
Influence on the Nervous System — Influence on the Nutrition— Conclusions 
— Therapeutic Applications of Bloodletting — Local Bleeding by Cupping — 
Leeches — Artificial Leeches — Mode of Application — Physiological Effects — 
Therapeutical Applications. 

THE TREATMENT OF ANAEMIA . 223 

History — Anaemia and Chlorosis — Different Kinds of Anaemia — Alteration of the 
Blood in Anaemia — Red Blood- Corpuscles, Their Composition— Oxy-Haemo- 
globin — Evolution of the Globules — Essential and Symptomatic Anaemia — 
Chlorosis — The Importance of Enumeration of the Globules, and Dosage of 
the Haemoglobin — Treatment of the Anaemias — Pharmaceutical Treatment — 
Iron — History — The Action of Iron — Absorption of Iron — Elimination of Iron 
— Mode of Introduction of Iron — Ferruginous Preparations — Reduced Iron — 
Oxides of Iron — Dialyzed Iron — Ferrous and Ferric Salts — Ferruginous 
Preparations in General — Ferruginous Waters — Artificial Ferruginous Waters 
— Choice of Ferruginous Preparations — Inconveniences of Iron Medication — 
Constipation— Blackening of the Teeth— Gastric Pains— Quantities of Iron 
Absorbed per Day— The Specific Action of Iron— Adjuvant Medications- 
Manganese — Arsenic — Hydrotherapy — ^Erotherapy — Hygienic Treatment — 
Alimentation— Must We Treat All Cases of Chlorosis ?— Pernicious Anaemia, 
Its Treatment. 



CONTENTS. XV 

TREATMENT OF ACUTE RHEUMATISM . 245 

Acute Articular Rheumatism — Natural Evolution of Rheumatism — Expectancy in 
Rheumatism — Divers Treatments of Rheumatism — Antiphlogistic Treatment — 
Bloodletting — Antimony — Anti-febrile Medication — Quinine — Local Treat- 
ment — Revulsive Method — Vesicatories — Anti-rheumatic Balms and Liniments 
— Hypodermic Injections — The Specific Medication — Alkalies —Salts of Sodium 
— Salts of Potassium — Acid Medication — Ammoniacal Salts — Propylamine 
and Trimethylamine — Cyanides — Salicylic Acid — History — Administration of 
Salicylate of Soda — Advantages and Disadvantages of Salicylate of Soda — 
Indications and Contra- Indications for the Salicylate Medication — Treatment 
of Local Rheumatism — Balneo-Therapy in the Treatment of Rheumatism — 
Sudorifics — Vapor Baths — Medicated Vapor Baths — Sulphur Baths — Resume 
of Treatment — Treatment of the Complications of Rheumatism — Treatment 
of Cerebral Rheumatism. 

TREATMENT OF CHRONIC RHEUMATISM AND GOUT ... 263 

Chronic Rheumatism — Origin of Gout and Chronic Rheumatism — Arthritism — 
Arthritis Deformans — Treatment of Arthritis Deformans — Internal Medication 
— Arsenic — Iodine and Iodides — Salicylate of Soda — External Treatment — 
Electricity and Massage — Thermal Treatment — Dietetic Treatment — Action of 
Cold — Gout — Pathogeny of Gout — The Uric Acid Diathesis — Etiology of the 
Uric Diathesis — Therapeutics of Gout — Treatment of the Fit of Gout — The Fit 
of Gout — Ought we to Treat the Fit of Gout — Visceral Complications of Gout 
— The Gouty Kidney — Bloodletting — Sudorifics — Guaiacum — Purgatives — 
Specific Treatment of Gout — Sulphate of Quinine — Colchicum — Preparations 
of Colchicum — Vegetal Treatment of Gout — Alkalies — Salicylate of Soda — 
External Treatment of the Fit of Gout — Resume of the Treatment of the Fit 
of Gout — Treatment During the Interval — Alkalies — Lithia — Bitters and 
Tonics — Thermal Treatment — Hygienic Treatment. 

TREATMENT OF DIABETES 285 

Concerning Diabetes — Its Frequency — Its Pathogeny — Physiological Glycaemia — 
Theory of Diabetes — Alimentary Theory — Nervous Theory — Theory of Dis- 
turbance of Nutrition — Glycosuric Urine — Tests for Glycose — Heller's Process 
— Boetger's Process — Trommer's Process — Dosage of Glycose — Duhomme's 
Method — Prognosis of Diabetes — The Diabetes of Fatty People — The Diabetes 
of the Lean — Grave Diabetes — Diabetes of Medium Intensity — The Mild 
Form — Hygiene of the Diabetic — Alimentary Hygiene — Bases of the Alimen- 
tation of the Diabetic — Regime of Cantani — Regime of Bouchardat — Regime 
of Seegen — Gluten Bread — Soups — Legumes — Fruits — Pastries — Alcoholic 
Beverages — Beverages in General — Glycerine — Resume of the Alimentary 
Hygiene — Exercise — Results of Treatment — Pharmaceutical Treatment — 
Anti-fermentative Medicaments — Lactic Acid — Narcotics — Valerian — Ergot 
of Rye — Iodine and the Iodides — Alkalies — Their Action in Glycosuria — 
Arsenic — Bromide of Potassium — Thermal Treatment of Diabetes — Electricity 
— Hydrotherapy — Local Treatment of Diabetes. 

TREATMENT OF SYPHILIS .3*° 

Origin of Syphilis — Necessity of the Mercurial Treatment of Syphilis— Mercury — 
History — Absorption of Mercury — Its Elimination — Elimination by Milk— 
Mercurial Salivation — Anti-Syphilitic Action of Mercury — Mode of Introduc- 



XVI CONTENTS. 

tion of Mercury — Dermic Method — Mercurial Frictions — Mercurial Baths — 
Hypodermic Methods — Injections of Ammoniaco-Mercurial Peptones — Respi- 
ratory Method — Dermo-Pulmonary Method — Mercurial Inhalations — Method 
per Os — Mercurial Preparations — Adjuvant Medications — Vegetal Treatment 
— Guaiacum — Pilocarpine — Iodide of Potassium — General Treatment — Method 
of Successive Treatments — Concerning the Cure of Syphilis — The Marriage of 
Syphilitic Persons — When Ought the Anti-Syphilitic Treatment to be Com- 
menced? — Necessity of Treatment — Are all the Manifestations of Syphilis Tri- 
butary to the Specific Treatment? — Treatment of the Indurated Chancre — 
Iodoform — Sulphide of Carbon — Treatment of the Stages — Mixed Treatment — 
Treatment of Mucous Patches — Treatment of Tertiary Syphilis — Treatment of 
Venereal Affections — Soft Chancre — Blennorrhagia — Its Treatment — Cubebs 
and Copaiba — Urethral Injections — Treatment of Gleet — Abortive Treatment — 
— Blennorrhagic Vaginitis — Vaginal Suppositories — Gurgun Balsam — Vaginal 
Injections. 



PART THIRD- 



FEVER FROM A THERAPEUTIC STAND-POINT 343 

Fever — Characteristics of Fever — Animal Heat — Clinical Thermometry — Its Im- 
portance from the Stand-Point of Prognosis, Diagnosis and Therapeutics — 
Antithermic Medication — Pathological Physiology of Fever — Combustions in 
Fever — Products of Elimination — Phenomena of Combustion — Calorimetry — 
Theories of Fever — Vaso-Motor Theories — Theories of Traube, of Senator, of 
Marey — Theory of the Augmentation of Combustions — Nervous Theories — 
Calorific Centres — Thermic Nerves — Humeral Theories — Pyretogenous Sub- 
stances — Therapeutical Deductions — Antithermic Medications — Physical Means 
of Subtraction of Heat — Cold Baths and Warm Baths — Subtraction of Blood — 
Bloodletting — Medicaments Acting on the Circulation — Digitalis — Ergot — 
Aconite — Veratrine — Antiseptic Medicaments — Quinine — The Aromatic Series 
— Phenic Acid — Salicylic Acid — Resorcin — Kairine. 

TREATMENT OF TYPHOID FEVER . . . . 365 

Typhoid Fever — Etiology — Spontaneity — Contagiousness — Theory of Typhoid 
Contagion — The Microbe of Typhoid Fever — The Virus of Typhoid Fever — 
Theories of the Contagion — Fecal Matters — Fecal Theories — Sewerage — Ali- 
ments — Overcrowding — Experimental Physiology of Typhoid Fever — Public 
Hygiene — Private Hygiene — Hygienic Treatment of Typhoid Fever — Alimen- 
tation — Oration — Cleanliness — Treatments of Typhoid Fever — Divisions — 
Antithermic Medication — Method of Refrigeration — Cold Baths — Brand's 
Method — Its Application — Its Results — Its Advantages — Its Disadvantages — 
Warm Baths — Refrigerant Apparatus — Cold Lotions — Cold Lavements — Anti- 
phlogistic Method — Local Bloodletting — General Bloodletting — Antipyretic 
Medication — Digitalis — Quinine — Antiparasitic Method — The Aromatic Series 
— Phenic Acid — Salicylic Acid — Resorcin — Kairine— Evacuant Medication — 
Purgatives — Calomel — Mercurials — Tonic Medication — Alcohols — Cinchona — 
Exclusive Medications — Their Dangers — Expectancy — Treatment of Indica- 
tions — Armed Expectancy — Bases of this Medication — State of the Forces — 
Intensity of the Fever — Treatment of the Complications — Nervous Complica- 
tions — Pulmonary Complications — Abdominal Complications— Conclusions. 



CONTENTS. XVII 

TREATMENT OF INTERMITTENT FEVER 412 

The Marsh Poison — Its Nature — Atmospheric Influences — Cinchona Fevers — Cin- 
chona Bark — Alkaloids of Cinchona — Quinine — Cinchonine — Cinchonidine — 
Quinidine — Quinoidine — Quinoleine — Physiological, Toxic, and Therapeutic 
Action of these Different Alkaloids — Superiority of Quinine — Absorption and 
Elimination of the Salts of Quinine — Sulphate Chlorhydrate, Tartrate, Brom- 
hydrate, Salicylate, and Tannate of Quinine — Mode of Administration — Pills 
— Potions — Gastric Method — Intestinal Method — Lavements — Dermic and 
Hypodermic Methods — Pomades of Quinine — Pulmonary Method — Intra- 
tracheal Injection of Quinine — Mode of Introduction — Modes of Administra- 
tion — English Method — Italian Method — French Method — Doses — Massive 
Doses — Fractional Doses — Duration of Medication by Quinine — Contra In- 
dications for the Employ of Quinine — Influence of Pregnancy — Succedanea of 
the- Salts of Quinine — Alkaloids by way of Synthesis — Quinolein — Aromatic 
Series — Salicylic Acid — Resorcin — Kairine — Cedron and Valdivine — Picric 
Acid and the Picrates — Arsenic — Animal Substances — Spider Web — Hygienic 
Treatment — Hydrotherapy — Thermal Treatment — Treatment of Pernicious 
Intermittent Fevers — Treatment of Paludal Cachexia — Conclusions. 

TREATMENT OF ERUPTIVE FEVERS 452 

The Eruptive Fevers — Variola — Its Prophylactic Treatment — Variolic Inoculation 
— History of Variolization — Vaccine — Importance of Vaccine — Its Results — 
Origin of Vaccine — Cow-pox and Horse-pox — Attenuated Virus — The Microbe 
of Vaccine — Animal Vaccine and Humanized Vaccine — Vaccination — Dangers 
of Vaccination — Vaccinal Syphilis— Vaccinal Tuberculosis — Activity of Pre- 
servation by Vaccine — Conservation of Vaccine — Importance of Vaccination — 
Treatment of Small-pox — Period of Invasion — The Rachialgia and the Con- 
stipation — Treatment of the Eruption — Abortive Mask — Period of Suppuration 
— Disinfectant Lotions and Baths — Cardiac Complications — Ether-Opium 
Medication — Period of Desiccation — Treatment of Complications — Hygienic 
Cures — Prophylactic Treatment of Scarlet Fever — Treatment of Measles — 
Treatment of the Eruption — Treatment of the Complications. 



INTRODUCTORY LECTURE. 

ON 

CLINICAL THERAPEUTICS. 

Summary : What is Meant by the Term Clinical Therapeutics? — Clinical Medicine and Clinical 
Therapeutics — Utility of Therapeutics— Scepticism and Enthusiasm in Therapeutics — 
Illusions in Therapeutics — Is Medicine an Art, or a Science? — Empirical and Experi- 
mental Therapeutics — Polypharmacy in Therapeutics — The Treatment of Symptoms 
— Constancy in Therapeutics — Necessity of Cool Judgment in Therapeutics — Accumula- 
tion of Doses — The Art of Prescribing — The Part of Hygiene in Therapeutics — The 
Part of Etiology in Therapeutics. 

Gentlemen: — I owe you an explanation of the words " Clinical Therapeu- 
tics " placed at the head of these lectures. What is meant by Clinical Thera- 
peutics? What are its limits? What has it to do with clinical study, what 
with the treatment of disease? This is what I will endeavor to explain. 

When you study therapeutics so-called, you pass in review the different 
medicaments which constitute the Materia Medica; you learn their natural 
history, their physiological properties, their dosage, and their various remedial 
applications. 

This method of studying is altogether theoretical. It is like commencing 
clinical medicine by learning about diseases, their march and their symptoms in 
treatises on pathology and practice. But in order that therapeutics, like 
pathology, may become practical, useful, productive, the theoretical notions 
which you have learned must be applied to the sick person. Moreover, as Clinical 
Medicine is the study of the modifications which different organisms impose on 
the course of morbid affections, so clinical therapeutics will enable you to 
appreciate in the living being the constantly occurring deviations from the pre- 
cise laws formulated by therapeutics properly so-called. 

To examine and survey the effects of the different remedial agents 
administered to the patient, and to study their indications, will then constitute, 
for us, clinical therapeutics. In pursuit of this knowledge you will learn not 
only how to handle medicines, but also how to associate them so as to constitute 
what has been described under the name of medication. No study is more 
practical, none more necessary. 

In this place, to insist on the necessity of therapeutics, would be absurd; 
medicine without therapeutics does not exist. All that you learn about medi- 
cine properly so-called, and the sciences accessory to it, has but one end and 
aim — to relieve and cure the patient. 

When you are called to visit a sick person, after having taxed all the 
knowledge you possess to enable you to arrive at an exact diagnosis, and after 
having carefully considered the prognosis, you are inevitably and fatally brought 
to face the question which your own conscience, your patient and those 



2 CLINICAL THERAPEUTICS. 

around him force upon you. What must be done? You will have to look to 
therapeutics for an answer, and the world will form its opinion of you much 
more from the skill with which you combat disease, than from the knowledge, 
however pretentious, which enables you to recognize and diagnosticate the 
disease. 

Far from our thought the intimation that one can be a good practitioner 
without a thorough understanding of clinical medicine and pathology; in order 
to institute a treatment and determine the indications, it is absolutely neces- 
sary to know accurately (as far as possible) the symptoms and natural 
tendencies of the malady which is before you. In fact everything in thera- 
peutics will be hesitating, mismanaged, incoherent, unless you begin by estab- 
lishing the treatment on a solid basis, which is an exact knowledge of the 
morbid affection. 

When occupied with therapeutics there are two dangerous rocks to shun: 
skepticism on the one hand, exaggerated enthusiasm on the other. To believe 
too much and not to believe at all are two opposite terms, but they are not so 
far apart as one might suppose. The one engenders the other, and extreme 
credulity gives rise to incredulity. 

Beware especially of skepticism. A physician who lacks faith in medicine 
has no more reason for existence than a priest who does not believe the religion 
he teaches, or a soldier who is destitute of love of his country and his 
flag. It is repugnant to reason and to conscience that he can be a good physi- 
cian who judges of no utility all the remedial agents that have the sanction of 
tradition and custom. 

But, on the other hand, it often happens that he who has the reputation at the 
hospital of being a sceptic in therapeutics becomes an over-zealous prescriber when 
at the bedside of his private patient. Believe then in your art, but that this belief 
may be judicious, reasonable, let it not suffer you to be too easily carried away 
by what you may deem the results of your medication; in therapeutics, illu- 
sions are indeed very frequent. This arises from numerous causes, especially 
from the propensity of the human mind to attribute all that eventuates favor- 
ably in the course of the disease to the medicine given, when very often it is 
only the natural evolution of the disease which the physician has observed. 

It is particularly in epidemic complaints that great prudence and extreme 
reserve should be exercised before drawing conclusions. The type of 
epidemics is variable, and according as this is mild or severe, therapeutical 
results are different. This explains to you why it has happened that certain 
remedies, exhibited with success in some epidemic and contagious diseases, in 
other seasons have failed to give as good results. This is an example of those 
therapeutic illusions which have encumbered the Materia Medica with so many 
drugs that have obtained a certain brief reputation in their day, soon to fall 
into forgetfulness and neglect until another experimenter repeating the trials 
of a bygone time, restores them to passing notoriety. 

This celebrity, then this decadence of remedial agents, are unfortunately 
facts of too great frequence in therapeutics. So, after having pruned away all 
the useless and superfluous substances of the Materia Medica, if you retain 



CLINICAL THERAPEUTICS. 3 

only those which medical practice has consecrated by long usage, you will find 
that the really useful medicaments are much less numerous than one would 
suppose, and your daily practice will include but a few drugs. 

For a long time the question has been discussed: "Is medicine an art or 
a science?" It is both. 

Medicine is a science by the many kinds of knowledge which it includes 
as a necessary part; it is an art by its application to the patient, and above all by 
its therapeutics. It is in this art that all the talent of the physician finds its 
proper exercise; it is by the form given to his preparations, by a happy choice 
of remedial agents, by their favorable combination, that the physician is a ver- 
itable artist. And when Trousseau pronounced these words he was himself 
the living personification of the fact, for no one ever carried farther than he 
the art of therapeutics. 

Follow no exclusive method; draw from all sources. Be not too solicitous 
for physiological explanations; do not demand for each drug an absolute experi- 
mentation which may explain its therapeutical action. Because you do not 
know the mode of action of quinine, do you any the less believe in its efficacy 
in intermittent fever? Because you are ignorant how mercury acts, does it 
cure syphilis any the less ? 

I am aware that by so speaking, I lay myself open to the charge of crass 
empiricism. It will be said, too, that I am diverting therapeutical practice from 
the new and scientific road, which it ought to pursue. But this road is scarcely 
marked out; only here and there a few stakes have been set, and unhappily 
these stakes are not very firmly placed. 

Experimental therapeutics, in fact, may be said to exist only in name. 
Being unable to induce in animals artificial disease, we cannot study on them 
the therapeutical action of drugs. We have scarcely been able to arrive at a 
knowledge of their physiological action; for we are too often obliged in order 
to obtain appreciable effects, to produce grave disorders, and to administer the 
drug in the state of poison rather than in the state of medicine. By this 
method, then, of studying the action of drugs, we have cultivated an experi- 
mental toxicology, rather than experimental therapeutics. Do not think, how- 
ever, that I would discourage these researches. You know, on the contrary, 
how much I prize them. You have often seen me in our laboratory, study the 
effects of medicines on animals; you have seen me examine attentively the 
symptoms produced. It is indeed an excellent study which has furnished valu- 
able data, but do not forget that it is only a complementary study. 

It enables us to give a tolerably plausible explanation of the action of the 
medicament, and especially to know the limits beyond which it is not safe to go, 
and at what moment the drug ceases to become medicinal and becomes a 
poison. But it is not physiological experimentation that decides the destina- 
tion of the medicament, or of medication ; it is the effect of the remedy on the 
sick man, and on the march of the disease which determines its therapeutical 
value. 

The history of therapeutics these last few years shows that it is by this 
mode of procedure that progress in this science has been made. Do you believe 



4 CLINICAL THERAPEUTICS. 

that it was as a sequence of experimentation on animals that chloral, bromide of 
potassium, alcohol, etc., were introduced into therapeutics ? No, the clinician 
first noted with care the favorable results obtained in the treatment of certain 
affections, then the facts reported were confirmed by the experience of others, 
and the experimenter applying the drug in his turn to animals studied the inti- 
mate mechanism and physiological action. 

It is, then, always to observation that you should have recourse; it is to the 
attentive examination of the patient that you should always return. Careful 
observation will enable you to study the action of the drug, to lessen or modify 
the dose according to the indications, and to decide the proper form for admin- 
istration. 

Do not employ too many remedies at the same time ; do not in your busy 
endeavors to serve your patient, inflict upon him medicines and medica- 
tions widely differing in their action. Study with care the disease which is 
before you ; go back to the origin of the morbid affection ; formulate the lead- 
ing indications resulting therefrom; decide concerning the diatheses which have 
influenced the course of the malady, institute a plan of treatment and endeavor 
to carry it out with a very moderate exhibition of drugs. 

During the years just passed, we have seen it gravely urged that we should 
treat diseases by meeting particular symptoms ; that is to say, by combating 
each of the morbid phenomena by a specific medication. This is, I believe (in 
very many cases at least), a pernicious course to pursue, and one for which there 
is little scientific justification. Instead of dispensing your medicines in this 
way, instead of introducing into the economy numerous substances differing in 
nature, differing often in their action, adopt an opposite method, that is to say, 
endeavor to find the point of departure of all the manifold symptoms, and to 
this, as the real cause, direct your medication. 

Be not too changeable, do not allow yourself to drift about at the caprice 
of your patient, who would fain experience immediately the benefit of the 
medication; learn to be patient and wait until the medicine has had time to 
produce all its effects. Husband well your therapeutical forces, do not expend 
all your efforts at once, follow the tactics of the army general, and to decide 
the victory, keep always strong reserves. 

Unhappily the physician in certain cases, called cases of urgency, often 
yields to the importunities of the family, who are frightened at the progress of 
the disease, and administers with lavish hand medicines that are heterogeneous 
and even incompatible. 

In the midst of the general disorder be calm and cool ; be not precipitate 
in the administration of remedies ; act rapidly, and with energy, but go right 
to the end you have in view, without stopping to meet secondary symptoms. 

Do not forget, especially if you institute a course of treatment which must be 
continued for some time, that a great many remedial substances, when given for 
a good while, either loose their effect, or produce cumulative effects in the 
economy. You must in these cases know how to suspend and interrupt the 
administration of the drug at the proper time, you must know also how to vary 
its administration, in order that the patient may not be disgusted with the 



CLINICAL THERAPEUTICS. 5 

remedy from long taking it. Remember also that the effects of the same medi- 
cines differ according as they are taken in massive or fractional doses. 

This is not all ; it is desirable that the physician should use the utmost care 
in prescribing his medicines. The hospital practice does not, unfortunately, 
favor this special study; we find ourselves in a particular situation which obliges 
us to formulate too rapidly and incompletely, so that after having followed for 
several years our hospital services, the most of you are almost entirely ignorant 
of the art of prescribing. 

This ignorance has more serious consequences than you think of, and if we 
see, in our day, pharmaceutical specialties having a constantly increasing im- 
portance, it is in some measure due to the fact that physicians do not acquire 
that expertness in the preparation of their medicines which they ought to 
possess, and prefer lazily to rely on the combinations of the manufacturing 
chemist, trade-mark preparations, or even the nostrums of the charlatan. 

But if by pursuing this course the practitioner often promotes the fortune 
of the pharmacist, he despoils himself in the end, for the patron, beguiled by the 
advertisements which accompany his nostrum, is almost certain to apply in the 
future, not to his physician, but to the vender of the trumpeted drug. 

Learn, then, skilfully to prescribe, and not only to write in an orderly and 
judicious manner the substances which compose your prescription, but also to 
render the combination as pleasant to the taste as possible. Repudiate, there- 
fore, in a general way, all the specialties which inundate the therapeutics of to- 
day. Exercise the greatest care in the directions which you give to the patient or 
his nurses ; do not fear to enter into the minutest details ; indicate how the ex- 
ternal applications should be made, and the times for giving the internal 
remedy; regulate carefully the little incidents of the day, and be particular 
about the diet. For you must ever remember that pharmaceutical measures go 
but a little ways in the cure of your patient, and that you can often accomplish 
more by hygiene than you can accomplish by medicine. 

Hygiene is, in fact, called upon to play a preponderating part in the treat- 
ment of diseases, and especially of chronic affections. To establish with care 
and in a scientific manner the bases of dietetics, ought to be one of the most 
serious occupations of the practitioner, and you will see in the course of these 
lectures the prominence which I give to hygiene in the treatment of diseases. 

By the side of hygienic therapeutics, it is also necessary to bring to light 
the importance of a study of the causes of the disease, for the old adage: 
Sublata causa tollitur effectus, is always true. Therefore, Professor Bouchardat 
was right in insisting that etiology is as indispensable to therapeutics as is 
hygiene, or the administration of medicines. 

Pardon me, gentlemen, for these remarks, but in undertaking the responsi- 
bilities of private practice, you will soon learn how all these details contribute 
toward the reputation which the physician enjoys. The patient cannot, in fact, 
judge of your technical knowledge, he appreciates simply the care which you 
give him, the devotion and skill which you display in such cases ; he forms his 
opinion of you and values you by the little details of our art. Do not think 



6 CLINICAL THERAPEUTICS. 

lightly then of these details, to which you will see me again and again return in 
the treatment of our patients. 

I hope I have shown you the utility of Clinical Therapeutics, and the 
farther we shall penetrate into the study which we begin to-day, the more will 
you be able to appreciate at their just value the results which I expect to obtain 
from this fruitful journey which we now undertake together. 



PART FIRST. 



TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 



ON THE TREATMENT OF DISEASES OF THE 
NERVOUS SYSTEM. 

THE NERVOUS SYSTEM FROM A THERAPEUTIC 
STANDPOINT. 

Summary: Difficulty of the Study of the Therapeutics of Diseases of the Nervous System — 
Moral Therapeutics — Structure of the Nervous System — The Nerve Cell — The Nerve 
Tube — Chemical Composition of the Nervous System — Phosphorus in the Nervous 
System — Action of Medicines on the Nervous System — Anaesthetics — The direct Action 
of Anaesthetics on the Nervous Elements — The Action of Alcohol — Effect of two 
Medicinal Substances on the Nervous Elements — Resistance to the Action of certain 
Medicaments — Action of the Nervous System on Nutrition — Action of Medicaments on 
the Vaso motors — Vaso constrictor and Vaso-dilator Medicines — Action of Ergot — 
Action of Morphia — Spasmodic and Anti-spasmodic Medicaments — Role of the Nervous 
System on the Secretions — Secretory Medicaments — Antagonism of Jaborandi and 
Atropine. 

Gentlemen: — I do not make light of, or conceal, the difficulties of the 
task which I enter upon to-day. The study of the treatment of nervous. dis- 
eases is, in fact, one of the most delicate and most difficult, for, to the hygienic 
and medicinal measures with which we have thus far been occupied, we must 
add a certain influence of a moral kind, exerted by the physician, an influence 
altogether personal, which plays often a preponderating part, and which consti- 
tutes a veritable moral therapeutic agency, respecting which it is not at all 
easy to furnish precise and exact data. That obscurity and that hesitation 
which attend us at every step in the treatment of nervous diseases, result from 
a number of circumstances. Although, during the last twenty years, the study 
of affections of the cerebro-spinal axis has made immense progress, and this 
especially in our own country, under the powerful and sage impulsion which 
Prof. Charcot has given to the School of the Salpetriere, there exists still, 
unhappily, numerous lacunae in this study. Physiology itself, which has 
accumulated, for a great many years past, an innumerable number of works on 
this special subject, is far from having solved all the problems of the vital and 
physiological functions of the nervous system. As for therapeutics, it must 
be confessed that this dspirtmant of medicine is still less advanced; not 
being able to base itself on positive physiological and pathological data, it 
has drifted about, having no guide but empiricism and tradition. 

I believe it my djty, however, to show you in these lectures the office 
of the physician in diseases of the nervous system, and what he can accomplish 
in certain cases by sage and reusonable therapeutic measures. But that you 
may well understand the difficulty of the subject of which I am going to 
treat, and how fragile the physiological and therapeutical basis is on which 

9 



10 ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 

rests the treatment of nervous diseases, I am going to devote this first lecture 
to the study of the nervous system from a therapeutic standpoint. 

The nervous system,* reduced to its simplest expression, may be repre- 
sented by two elements, a nerve-cell and a conducting tube. 

The nerve-cell, as you are aware, is composed of three parts : a nucleus, 
enclosing a nucleolus in its centre, a peripheral, homogeneous substance, and 
an excessively fine envelope. These cells present prolongations, more or less 
numerous, and their volume offers variable dimensions. 

As for the nerve tube, it possesses an investing membrane — the neuri- 
lemma. This neurilemma surrounds the nerve-fibrils, wnich are themselves 
constituted of three parts: an axis cylinder, continuation or prolongation of 
the cell ; a transparent membrane, constituted by the myeline ; and an external 
tunic. 

* The nervous system may be reduced to two elements, a nerve cell and a nerve tube ; 
it is the association of these two elements which constitutes nerve centres and nerves. 

Each nerve cell is composed essentially of three parts : a nucleus, protoplasm, and an 
envelope. The central nucleus, sometimes vesicular in appearance, contains a nucleolus. 
The peripheral substance is homogeneous, and presents different tints. Heckel, of Mont- 
pellier, has shown that lead and certain mineral substances color certain parts of this 
protoplasm black. In fine, the utricular tunic which invests it is sometimes so thin as to be 
scarcely visible. 

These cells may present prolongations or be deprived of them, whence the names, 
apolar cells, monopolar, bipolar, multipolar. According to certain authorities, and in par- 
ticular Stilling, this first group of apolar cells does not exist, and results from a fault in the 
preparation, or from the alteration of the cell. The filiform prolongations of the cells may 
be ranged in two classes : intrinsic prolongations and extrinsic prolongations. The first go 
from one cell to another cell or group of cells ; the extrinsic fibres pass to motor or sensory 
organs, and constitute the principal part of nerve cords. 

The nerve cord is constituted by an envelope of connective tissue, known as neurilem- 
nea, and by the juxtaposition of a series of primitive nerve fibres, more or less numerous. 
The nerve fibrillar are composed of three parts : a central axis cylinder, an external tunic 
or sheath, and an intermediate substance described under the name of medullary cortical 
substance, or myeline. These tubes have a variable diameter. Koliiker has classed them 
in the following manner : Very fine tubes, whose dia. does not exceed 2 m. (2- 1000 of a milli- 
metre) ; somewhat larger tubes, with a dia. of 2 to 4 m. ; middling sized tubes of 4 to 9 m.\ 
and large tubes with a dia. of 9 to 20 m. 

The medul'ary substance which is situated between the sheath and the filiform axis 
cylinder, is transparent and viscous, and gives to nerves their white and pearly appearance. 
This laver is the most alterable, and in coagulating it gives to nerves a variable appearance. 

The axis cylinder is the essential part of the nerve tube ; it has a very complex struc- 
ture, as Stilling has shown. It is striated longitudinally and transversely, and this last 
appearance has led Grandry to think that it is composed of a series of alternating disks. 
Roudanowsky has stated the opinion that the axis cylinder may give origin to lateral off- 
shoots which cause inter-communication between the different tubes of a nerve cord. In 
fine, the axis cylinder is a direct continuation of the extrinsic prolongations of the cells (a). 



(a) Heckel— De quelques phenomenes de localisation de matiere tninerale et organique chez les mol- 
lusques (Comp. rend, de l'Acad. des Sc, 1874, t. CXXIX, page 614). Stilling— On the Structure of the Nerve 
Cell (Comp. rend, de l'Acad. des Sc, 1865. t. XII., p. 899). Koliiker— Elements ot Histology, p. 314. Grandry— 
Jour, de Anatom , 1869, t. V., p. 289. Roudanowski— Observations on the Structure 01 Nerve Tissue (Jour, 
de l'Anat. de Robin., 1865, t. II., p. 231). Milne Edwards— Lessons in Physiology, t. xi., p. 152. 



ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 11 

As for the chemical composition of these substances, it has for its basis cer- 
tain phosphorized oils, whose essential principle, according to Liebreich, is a 
neutral phosphorized body, which he has described under the name of pro- 
tagon* 

These cells and these nervous tubes, associated in divers ways, constitute 
the nervous system in its entirety. I do not propose to enter into details of this 
structure; this is a point quite outside of my subject, and which would demand 
for its complete exposition, numerous lectures. But I desire, before going fur- 
ther, to draw a first conclusion from the several particulars which 1 have just 
stated respecting the constitution of the nervous system. I refer to the appli- 
cation of phosphorized substances, and of phosphorus, to the treatment of 
diseases of the cerebro-spinal axis. 

From the fact that nervous substance contains a large proportion of phos- 
phorus, it is by no means demonstrated that the diseases of the nervous 
system, and in particular temporary perturbations of this system, such as those 
which constitute hysteria, for instance, are accompanied by a diminution of the 
phosphorus contained in the protagon. And even were this fact demonstrated, 
it would be necessary to prove that phosphorus, or phosphorized substances 
introduced by way of the stomach, are utilized for the nutrition of the nervous 
system; which is very doubtful. We encounter here (and shrouded in even 
greater obscurity) the same therapeutical problem which met us in the past, and 
which meets us to-day, respecting the action of ferruginous medicines. From 
the fact that iron is a constituent of the blood, we do not the better understand 
the modus operandi of chalybeate preparations. So we ought not to conclude, 
because phosphorus is an integral part of the nervous system, that therefore, a 
priori, tue preparations of phosphorus are indicated in diseases of the system. 

Seat of intelligence, sensibility, and movement, the nervous system plays a 
still more important part when we study its influence on nutrition throughout 
the entire animal series. The celebrated experimentation of Claude Bernard, 

*The nervous substance is composed of water, albuminous matters, salts and phosphor- 
ized fats, besides fats that do not contain phosphorus. Among the latter are oleine, stearine 
and cholesterine. The former, first described by Vaquelin in 1812, constitute, according to 
Bibra, 14 per cent, of the weight of the cerebrum, and have from 1 to 1.5 and even 1.9 per 
cent, of phosphorus. Fremy has described among these phosphorized fats two acids which 
he calls cerebric and oleo-phosphoric acids. 

According to Liebreich these substances come from the decomposition of an azotized 
neutral body containing phosphorus which is found in the brain and is described under the 
name of protagon. When this protagon is subjected to ebullition in presence of baryta water, 
certain acids are obtained, stearic and phosphoglyceric acids, an acid non-azotized, and a 
base which Liebreich has described under the name of neurine. 

Coeurbe has also described as of cerebral origin certain fatty substances, under the 
name of cerebrates and stearoconotes, but these seem to be artificial conpounds — (a) 



(a) Milne Edwards — Cours. de Phys. (Cotnp., t. XI. p. 153). Vauquelin — Analysis of Cerebral Matter 
in Man and in Certain Animals (Ann. de Chimie , 1812, t. LXXXI.). Bibra— Vergleicherde Untersuchungen 
uber das Gehirn. Fremy— Researches on the Brain of Man (Comptes rend de l'Acad. des Sc., 1840, t. XI. 
p. 163). Liebreich Ueber die Beschaf. der Gehirnsubstanz (Arch, de Chem. and Pharm.. 1865, t. 134, p. 29). 
Coeurbe— The Brain Considered from a Chemical and Physiological Point of View (Jour, de Chem. Med., 
1834, t. X). 



12 ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 

in 1851, opened new and unlookedfor horizons respecting the rSIeoi the nervous 
system in the organism; and leaving one side all the discoveries which have 
flowed from this experimentation, I will consider only those which have a bear- 
ing on therapeutics. 

Heretofore, in the study of medicinal substances, their action on the blood, 
and on the parenchyma of the viscera, was alone taken into account; it was 
thought that medicaments introduced into the economy modified the constitu- 
tion of the blood, and even the tissue elements themselves, and from this double 
action their therapeutic and toxic effect was derived. The discovery of the 
vaso-motors, in showing us that the circulation, secretion, intimate nutrition of 
the tissues are under the dependence of special nerves — vaso-constrictors, vaso- 
dilators, trophic nerves — has considerably modified this experimental study, and 
even suggested the thought that henceforth the key to the great problem of the 
physiological and therapeutical action of the greater part of medicinal substan- 
ces is to be found in the influence of these substances on the nervous system- — 
on nerve-tubes and nerve cells. 

My duty now is to point out to you what are the positive facts pertaining 
to this subject, and what, unfortunately, are the too numerous points of uncer- 
tainty and obscurity. 

I cannot examine all the medicinal substances and acquaint you, for each 
one of them, with the positive and negative facts which are furnished us by 
experimental therapeutics, concerning their action on the elements of the 
nervous system. 

This task would be immense, and would embrace therapeutics in its entirety. 
I have time only to consider briefly certain medicaments in their action on the 
cerebro-spinal or vaso-motor apparatus, and whose effects have been the most 
studied and are the best known. 

Those medicaments which act on the cerebro-spinal axis, and whose effects 
are best known, are certainly the anaesthetics, which modify and alter, at a given 
moment, the functions of the nervous system. I propose here to examine, with 
reference to their modifying action on the nervous system two substances — 
chloroform and alcohol. 

Claude Bernard has given us a series of experimental researches on the 
action of chloroform, which are a model of their kind. In one fundamental 
experiment he shows us first of all, that chloroform cannot act unless it be 
absorbed by the blood and carried to the cerebro-spinal axis. I spoke of this 
last year when treating of the penetration of medicaments by the air passages, 
and will not return to it now. By repeated experiments he sought and obtained 
a solution of the second part of the problem which he set before himself, namely, 
what is the role respectively of the cerebrum and the spinal cord in this 
anaesthesia? Both are affected independently by anaesthetics; but the cerebrum, 
as Claude Bernard says, is the centre of centres; that is to say, when it is under 
the influence of chloroform, the anaesthesia generalizes itself over the whole 
economy, while, on the other hand, when the spinal cord alone is affected, the 
anaesthesia extends over only a limited zone of the organism. 

By an attentive study of the phenomena which characterize the action of 



ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 13 

anaesthetics, the illustrious physiologist shows that the cerebro-spinal axis is not 
affected in all its parts at the same instant, and that, on the contrary, each one 
of them successively submits to the influence of the medicament. This order 
of succession is the following: The brain is first taken, and the consciousness 
of the ego is at once lost, but the spinal cord remains intact, and the reflex 
movements of the whole body persist. In a more intense degree of anaesthesia 
the spinal cord in its turn is overcome, but the medulla oblongata remains 
unharmed, presiding over the movements of circulation and respiration, which 
continue their function in a veritable cadaver, where every other sign of life has 
disappeared; the reflexes are abolished, anaesthesia is general, muscular collapse 
is absolute. But if you keep on increasing the dose of chloroform, the 
rachidian bulb is taken in its turn, and the animal succumbs; and in the inter- 
esting communication which he has lately made to the Academy of Medicine, 
Vulpian has shown us that if the rachidian bulb seems to be intact, it is never- 
theless affected, and that in a chloroformed animal, it is only necessary to induce 
a slight nervous shock to suspend the functions of the medulla oblongata in its 
turn. 1 

By these experiments we see clearly set forth the part which pertains 
respectively to the circulation and to the nervous system in the action of the 
medicinal or toxic substance ; the circulation bringing from the periphery to 
the nerve-centres the medicinal substance, and these, when affected by the 
medicament, generalizing the effect from the centre to the periphery. But 
this does not suffice ; it is necessary to penetrate further into the subject, and 
demand what is the intimate action of chloroform on the nerve elements them- 
selves. Claude Bernard has shown us by experiments of rigorous precision, 
that in the case of sensory nerves this momentary loss of their functions is 
absolutely analagous to what takes place when the sensory nerves succumb to 
abstraction of blood ; or, if you prefer this statement, that troubles of sensi- 
bility manifest themselves at the periphe/y, while the action of the medicine is 
exerted on the centre (*. e., the nerve-cells), in accordance with the law laid 
down by M. Bernard: "the nervous element loses its properties by the 
extremity opposite to that where it is affected." 

But what is the alteration of the nerve-cell produced by the contact of 
chloroform conveyed to it by the blood ? Here we can only make hypotheses. 

1 The respiratory centre in the medulla oblongata possesses a considerable resistance to 
the action of chloroform, but it is paralyzed in part, as the following experiment, performed 
by Vulpian, shows: In an animal not chloroformed, in which the pneumogastric nerve has 
been cut, if you electrize the central end of the nerve you determine complete arrest of the 
respiration; this lasts half or three-quarters of a minute. If you continue the electrization, 
the respiration resumes its course, and in order to obtain a new arrest of the respiratory 
movements, you must suspend for a time the electrization, to return to it again. In an 
animal plunged in the sleep of anaesthesia, electrization of the central end of the pneumo- 
gastric arrests respiration more readily than in the first case, and after this suspension the 
respiratory movements do not, of their own accord, come back again, and the animal, aband- 
oned to itself, dies of respiratory syncope. This shows that the rachidian bulb is not in its 
normal state, and that the respiratory centre is weakened. — Vide Dictionnaire de Therapeu- 
tique, D. Beaumetz, 1882, page 237. Trans. 



14 ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 

The most probable is that which Claude Bernard has offered, viz., that chloro- 
form causes an incomplete coagulation of the protoplasmic substance surround- 
ing the cell nucleus, that this coagulation is temporary, but that, under certain 
circumstances, it may be final. 

The solution of the problem in therapeutics, which I have stated, is not yet 
complete, for there is another element of the nervous system which is to be 
taken into account, viz., the great sympathetic, which modifies, in its turn, the 
circulation, and especially that of the brain, and produces there that anaemia 
which is such a factor in the anaesthetic sleep, as well as in natural sleep, as 
Hammond and Durham were the first to show us. The effects, then, of anaes- 
thetics may be partially explained by the action of the chloroform or other 
medicament on the ganglionic centres of the vaso-motor system. 

What I have just said of chloroform, I may almost repeat, word for word, 
of alcohol. It also is carried by the circulation to the nerve-centres. Like 
chloroform, it disturbs, more or less, the action of the cerebro-spinal axis, deter- 
mining at first phenomena of intoxication, then collapsus. Like the former, 
too, it modifies locally the circulation. So, then, certain substances penetrate, 
by the circulation, to the nerve-centres, and fix themselves there; as for alcohol, 
this fact is undeniable, and by direct researches on animals, and even on man, 
I have determined the presence of alcohol in the brain tissue itself. Other 
medicinal substances also localize themselves in the brain, and I cannot furnish 
you a better example than lead; in fact, saturnine encephalopathy is produced 
by the presence of this metal in the cerebral tissue, as has been proved by 
chemical analysis. Heckel has even shown that in animals submitted to lead- 
poisoning, this element, in fixing itself in the cerebral substance, alters the color 
of it. 

So it is now known that certain medicaments, which produce modifications 
in the functions of the cerebro-spinal axis, act directly on the nerve-cells, and by 
their presence determine transient or permanent results, which modify the 
property of those cells ; here, then, is a first fact which seems to be sufficiently 
established. 

I must add that it is essential that the nervous elements be intact, and this 
is a point to which I desire to call your attention, for it is of capital importance 
from a therapeutic point of view. We know, in fact, that under the influence 
of modifications, such as are determined by alcohol or by cerebral derange- 
ments, patients acquire a certain immunity from the therapeutic, and even from 
the toxic action of a gieat number of medicaments. We can, for instance, 
give to alcoholic patients, when affected with delirium tremens, or to maniacal 
patients, immense doses of morphia, atropia, or digitalis, without producing 
any symptoms of poisoning, although the same doses, in the same individuals, 
when in health, would speedily produce dangerous, if not fatal, symptoms. 1 

•I have seen teaspoonful doses of tincture of digitalis given in delirium tremens and in 
mania without any very perceptible effect. There is the same tolerance of chloral. I have 
given as much as three drachms ( 3 iij) in one night to a patient in delirium tremens, without 
producing any profound sleep; have seen five grains of morphia by mouth prove futile. — 
Trans. 






ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 15 

How shall we explain these facts? We can give a physiological explan- 
ation, based on a curious experiment of Claude Bernard and Paul Thernard. 
They etherized hares, then injected anhydrous prussic acid under the skin. 
Whenever the animal was plunged in the anaesthetic sleep, they could give him 
quite large doses of prussic acid without producing poisoning, but toxic symp- 
toms appeared as soon as the animal recovered consciousness and sensibility. 

This experiment is fundamental, and brings out with great clearness the 
capital fact, that when a nervous element is influenced or modified by a medi- 
cinal agent previously taken, it cannot be easily impressed by any other medi- 
cament. This explains the variable susceptibility to toxic drugs which 
some persons manifest — the tolerance of the nerve cells for one modifier of 
function when influenced by another — the cases of mania above referred to, 
also those of alcoholic poisoning, where morphia in very large doses is borne 
with impunity. But as the action of the cerebro-spinal axis is in relation with 
the activity — greater or less — of the circulation, it is apparent that it is quite 
possible to modify the functions of the nervous system by modifying the circu- 
lation through the agency of medicinal substances. This it is that leads me to 
speak of the action of medicines on the vaso-motors. 

Since the discovery of Pourfour du Petit,' since more especially the curi- 
ous experimentation of Claude Bernard, we know that the capillary circulation 
is dependent on the nervous system. This discovery immediately threw light 
on the actions of a great number of medicaments, and an attempt was made 
to divide them into two distinct groups, the one consisting of medicines that 
act on the vaso-dilators, the other of such as act on the vaso-constrictors. 3 

In the first group (the vaso-dilators) were placed curare, opium and its 

2 According to Vulpian, medicines which act on the vaso-motors are divisible into two 
groups, as given in the text {vide supra.) These vaso-motor effects may be produced in var- 
ious ways. Toxic substances may act on the unstriped muscular fibres directly, or pri- 
marily on the nerves, or vaso-motor nerve- centers. The effect of medicinal substances on 
the circulation has been studied, by direct examination, i. e., by the sight, by the haemady- 
namometer, and by the sphygmograph (Bordier's method); then by successive destruction of 
the vaso-motor nerve filaments, or vaso-motor centres, it has been attempted to limit the 
action of the substance under experimentation. Nevertheless, despite all the scientific rigor 
brought into these investigations, only confused and uncertain results have been obtained. — 
(Vulpian, "Legons sur l'Appareil Vaso-moteur," t. ii. p. 724, 1875). 

3 The discovery of the vaso-motors goes back to 185 1, when Claude Bernard made the 
experiments referred to. At the same time the contractility of the vascular system 
had long been known. Senac, Ens and many others had affirmed this contractility. Poufour 
du Petit, in 1727, had pointed out the redness of the conjunctiva which follows section of the 
cervical sympathetic cord, and Cruikshanks and Arnemann, repeating the experiments, had 
obtained the same effects. Bat it is Dapuy of Alfort, who, with Brechet, in the presence of 
Dupuytren, in 18 16, made the most decisive experiments concerning the action of the great 
sympathetic on the circulation. 

The first contribution of Claude Bernard bears date 1851, and consists in a short note 
to the Society of Biology. He showed that on removing the superior cervical ganglion in the 
hare, there is produced an augmentation of heat and a congestion of the ear on the same 
side. Then appeared a work of Brown-Sequard, which showed that on irritating the upper 
end of the nerve you obtain contraction of the dilated vessels. 



l6 ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 

alkaloids, eserine, and nitrite of amyl. In the second (or group of the vaso- 
constrictors) 1 a place was assigned to strychnia, ergot, belladonna, atropia, and 
the greater part of the poisons of the heart. 

Unfortunately it must be admitted that this division of medicines is based 
rather on hypothesis than on any rigorous scientific demonstration of their 
action; and in order to show you how difficult is the subject, I will take from 
the two groups two substances, and will tell you what we know that is positive 
concerning their vaso-motor action. As representing vaso-constrictive medica- 
ments, I will select ergot ; as a vaso-dilator medicament, morphia. 

It was in 1849 that a Belgian physiologist, Savet, affirmed for the first time 
that ergot of rye, whose ecbolic action was well-known, causes the arteries to 
contract. John Simon, in England, in 1850, taught the same doctrine, and both 
maintained that this constrictive action on the arteries was concerned in all the 
pharmaceutical and toxic properties of the drug. 2 But before these statements 
could be accepted as fact, they must be demonstrated by experiment, and 
Holmes, Wernich, Schuller, Vogt, showed in frogs, as well as in higher animals, 

*In frogs poisoned by nicotine, Claude Bernard has seen arrest of the circulation in the 
interdigital membrane, and contraction of the arterioles. Hence he affirmed that nicotine 
has a vaso-constrictive action. In Vulpian's opinion, this arrest of the circulation is due to 
disturbance of the functions of the heart. It has been asserted that in animals poisoned by 
this drug (" nicotinized ") the intra-arterial blood pressure is raised. Vulpian maintains, on 
the contrary, that if you will take the precaution to prevent all convulsive action by curariz- 
ing the animal, you will always find the blood pressure lowered, and there will be a marked 
congestion of the digestive tube, and especially the stomach. Sever the pneumogastrics in 
the neck, and there is no longer fall of the blood pressure. Heidenhain has shown that 
nicotine prevents the secretion of the submaxillary gland, without acting on the vaso-motors. 
From all this, it appears difficult to affirm that nicotine acts specially either on the vaso- 
motors or muscular fibres, and its action seems to be more complex than has been supposed. 
— Claude Bernard, "Legons sur les substances toxiques et medicamenteuses," 1857, p. 402, 
et seq. Heidenhain, Pfluger's Arch., t. v. p. 40-45. Vulpian, loc. cit., t. ii. p. 139. 

2 Savet, of Belgium, in 1849, and Simon, in 1850, first expressed the opinion that ergot 
caused the arterioles to contract. Savet attributed to contraction of the arteries all the 
phenomena which ergot determines (contraction of the uterus, of the bladder, etc.) Simon, 
on the other hand, affirmed a specific direct action on the unstriped muscular fiber every- 
where. Holmes (These de Paris, 1870), has studied experimentally the action of ergot 
on the circulation. Injecting ergotine into the tongues of frogs, he has noted arterial con- 
striction lasting twentv-five to thirty- five minutes. This effect was also noticed in the inter- 
digital membrane after section of the sciatic nerve. He concludes that ergot has a direct 
action on the muscular fibre of the arterial walls. 

Wernich, in experiments on hares and cats, has seen certain arterioles of the ear and 
pia mater contract, and this contraction takes place even after section of the sympathetic, 
which innervates these vessels. Schuller has obtained the same effect in the vessels of the 
pia mater, after section of the cervical sympathetic. 

Vogt, on the other hand, affirms that the active principles of ergot of rye act on the 
vaso-motor centres. 

Vulpian is of opinion that these experiments are not demonstrative, and that the direct 
action of ergot on the smooth muscular fibre has not yet been substantiated. — Holmes {loc. 
cit.), Vulpian {loc. cit.), Wernich {Virc how's Arch., 1872, t. 56, p. 19), Schuller {Centralblatt, 
1871, No. 51), Vogt {Berlin, klin. Wochenschtift, 1872, No. 10), Labadie Lagrave, L'Ergot de 
Seigle en France, et en Angleterre {Gaz. Hebdom., 1873, p. 249). 



ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 17 

cats and hares, the constrictive action on the arteries of these animals of ergot 
of rye and of ergotine. 

But how is this action on the unstriped muscle of these arteries effected? 
Is it a direct effect, or is it brought about by an influence on the constrictor 
nerves ? Here experiments are contradictory. Wernich and Schuller affirm 
that the contraction takes place when the vessel is deprived of all the nerves 
which it receives from the great sympathetic ; Vogt, on the contrary, affirms 
that the vaso-constrictive action of ergot results from modifications wrought 
in the vaso-motor centres. As you perceive, physiology has not given a clear 
answer to the question, and, as Vulpian well says, we have as yet no decisive 
test-experiment on either side. 

We find the same difficulty, apropos, of the study of morphia. Doubtless, 
morphia brings about a congestion of the face, causes constriction of the pupil, 
and seems to produce a relaxation of the unstriped muscular fibres. But how 
is this action effected ? This is a problem not yet solved. 

Whatever may be the modus operandi, one may nevertheless say, taking his 
stand on data already acquired, that the group of spasmodic and anti-spas- 
modic medicaments owes its therapeutic action solely to the effect which these 
substances produce on the smooth muscular fibres, and that this effect is more 
likely indirect, being primarily exerted on the vaso-motors. It is, in fact, very 
difficult to affirm, with all the care that one may take in conducting the experi- 
ment, that one has destroyed all the nervous elements which innervate a group 
of muscles, or the walls of a bloodvessel. Moreover, in sectioning the nerves, 
the terminal extremities of the nerves still exist, and it is probable, I affirm, that 
it is by acting on these extremities that the contraction or relaxation of the 
muscular elements is produced. 

But this is not all ; medicaments act also on the secretions, and we must 
recognize the fact that this is one of the most important results that we look for 
in the administration of remedies ; whether it be the kidneys, the salivary 
glands, or the skin with which we are concerned, we acknowledge the remedial 
efficacy, in morbid conditions of these organs, of diuretics, sialagogues, and 
sudorifics. 

Till quite recently, it was supposed that certain principles contained in 
these medicaments, by a direct action on the glandular element itself, promote 
secretion ; to-day, since the discovery of secretory nerves, this theory ought to 
be abandoned, and the admission made that these medicines act either directly 
on those nerves, or on the unifying substance which binds them to the secre- 
tory elements. 

But in order to show you, gentlemen, on what experimental data is based 
this new method of regarding secretory medicaments, I shall finish this lecture 
by briefly reviewing the curious experiments which have been made concerning 
the action of jaborandi and atropine on certain salivary glands. 

Among these glands is one which lends itself readily to experiment, as far 
as the nerves which innervate it are concerned — the submaxillary. This gland 
receives two sets of nerves ; one set comes from the lingual branch of the 
inferior maxillary, and from the chorda tympani ; another set comes from the 



18 ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 

superior cervical ganglion. By destroying the latter, or cutting the former, one 
may study the influence of these two sets of nerves — whose origin is so different 
— on the secretion of this gland, for a tube introduced into Wharton's duct en- 
ables you justly to estimate the flow of saliva in the curarized animal. 

When the chorda tympani is irritated, the circulation in the gland and the 
glandular secretion are augmented. 1 Heidenhain was the first to show that when 
an animal is poisoned by atropine, irritation of the chorda tympani produces 
augmentation of the circulation, but does not provoke the secretion of saliva ; 
the atropine then has acted on the secretory nerves, but it has respected the 
vaso-motors. And if any one should say that the atropine has directed and 
limited its action to the secreting cell, whose effect it has destroyed, the reply 
is that we can restore the secretion of saliva by exciting the branch of the 
great sympathetic, which fact proves that the glandular parenchyma is not 
altered in its functions. 

In another animal submitted to similar experiments, but treated by subcu- 
taneous injections of pilocarpine, instead of atropine, an increase in the secre- 
tion of saliva was noted. When, moreover, both these alkaloids were intro- 
duced, the one after the other, in the same animal, the phenomenon of exag- 
gerated secretion was no longer seen, these two substances being in therapeutic 
antagonism. What does this experimentation show? It is this — that jaborandi 
does not determine the salivary secretion, as Gubler thought, by the presence 
of certain of its principles in the secreting cell itself, for we have seen by the 
first experiment that atropine does not destroy the properties of the cells, but 
that there is a special action on certain elements, which it remains for us to 
designate. What is the anatomical element on which atropine, on which jabo- 
randi acts? Is it the nervous element itself? First of all, we must exclude all 
action on the nerve centers or nerve tubes. We have seen the action of atro- 
pine and jaborandi manifested in animals in which had been extirpated both 
the chorda tympani and the nerves from which it is derived, and the ganglia of 
the sympathetic; the effect then of these two medicaments must be exerted, if 
at all, on the peripheral portion of these nerves. But between the extremities 
of the terminal filaments of the branches of the sympathetic and those of the 
chorda tympani, from an anatomical point of view, no difference exists, and it 
is difficult to admit that a medicinal or toxic substance, introduced by the cir- 
culation, can leave intact the structure of one set of fibres, while altering the 
structure of the other. 

It is probable, then, that it is not on the extremities of the nerve-fibres- 

1 When, after cutting the chorda tympani, you excite the peripheral end of that nerve, 
all the bloodvessels are seen to dilate, and the salivary secretion augments. Nevertheless, 
these two effects, the vaso-motor and the secretory, are distinct, for woorari, given in a 
certain dose, paralyzes the secretory action, without at all modifying the vaso-motor action. 
The same result is obtained with atropine or cicutine. The experiments of Vulpian, of Hei- 
denhain, and of Joliet, are, in this respect, absolutely demonstrative. There are, then, 
medicaments which act on the nerves of secretion, without acting on the vaso-constrictors, 
or vaso-dilators. — Vulpian, "Lecons sur les Substances Toxiques et Medicamenteuses." 

J Covne has studied the terminations of the nerves in glands. He has found, under the 



ON THE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. 10 

that such toxic substances as jaborandi and atropine act, but rather on the 
"unifying substance," which is interposed between the nerve terminations of 
the chorda tympani, or sympathetic, on the one hand, and the secreting ele- 
ments on the other. 

What is this "unifying substance?" Here is a great anatomical and physi- 
ological problem which is not yet solved, and it is for the future to define it, 
and to assign to it its part in the process of secretion. 

But I ought to assure you, that if the difficulties of these physiological 
problems augment in proportion as experimental analysis becomes more 
rigorous, it is none the less true that such researches give scientific precision to 
the study of the actions of medicines, and that it is in this way only that ex- 
perimental therapeutics can progress. 

Such are the general considerations that I desired to present to you rela- 
tive to the nervous system considered from a therapeutic standpoint; they show 
you the difficulties of the problem and how these researches should be con- 
ducted in the future.* 

limiting membrane of the parenchyma, triangular or elongated cells, with multiple prolon- 
gations, having all the characters of nerve cells. He has been able to follow the nerve 
fibres through to the cells, but has not succeeded in finding the connecting substance which 
binds the cells to the epithelial elements. Pfli'iger has described very fine nervous filaments 
terminating in the epithelium itself, but he is the only one who has yet traced these termina- 
tions in the epithelium of glands. Rouget disputes Pfli'iger's assertion that the fibres dis- 
covered by him were nervous filaments, for they keep their sheath of myeline to their termi- 
nation in the gland substance — an exception to the general rule. 

Hermann, in observations of sweat glands, has seen fine nerve filaments in the limit- 
ing membrane of the glands. Cadiat explains the presence of these nerve filaments in 
this situation by the fact of the existence of a great number of muscular fibres in the par- 
ietes of the glands; he thinks that Hermann's nerve filaments are destined to innervate 
these muscular elements. (Coyne, "De la terminaison des nerfs dans les glandes," Comptes 
Rendus de l'Academie des Sciences, 1878). Cadiat, "Traite d'Anatomie Generale," t. 
ii. P- I53-) 



ON HYDROTHERAPEUT1CS. 

Summary. — History of Hydrotherapy — Priessnitz — Physiological Action of Cold — Reaction 
— Action of Hydrotherapy — Action on the Nervous System — Action on the Circulation — 
Action on Nutrition — Mode of Application of Cold Water — Douches — Pressure of the 
Water — Temperature of the Water — Alternating Douches — Duration of the Douche — 
Sudation before the Douche — Immersions — Affusions — Applications of Ice — Pulveriza- 
tions of Ether. 

Gentlemen: — Applied from the earliest antiquity to the treatment of certain 
affections, cold water did not take its proper place among the resources of our 
profession till almost the very epoch in which we live. It was as a result 
of the efforts of a simple peasant, a kind of country quack, and not till 
after his empirical employment of the remedy, that scientific labors were 
undertaken to explain the effects, and to determine the* indications of cold 
water applications. 1 

At Graefenburg, a village of Austrian Silesia, lived, at the commencement 
of this century, a certain Priessnitz, a very observing and intelligent man, who 
had noted the beneficial effects of cold water treatment on sick animals confided 
to his care. 

Imagining that diseases impregnate a man as liquids do when they pene- 
trate a sponge, he maintained that in order to cure them it sufficed to remove 
morbid impurities from the cutaneous surface by repeated bathings and the 
promotion of the excretory function of the skin. He therefore applied cold 
water to the treatment of the greater part of diseases, and modified successively 
the divers procedures of hydrotherapy which he put in practice. At first he 

1 Hippocrates, in his treatise on "Air, Waters and Places," insists on the use of cold 
water in the treatment of diseases. The Romans made great account of hydrotherapy, and a 
certain Charmis maintained that all diseases were curable by cold water alone. Celsus, 
Aretseus, Ccelius Aurelianus, all pronounced in favor of cold water medication, and recom- 
mended treating fevers by this means. Then it fell into desuetude till the seventeenth 
century. 

In 1638 Louis Septala recommended cold douches; then a Belgian, Hermann Van der 
Heyden, employed them in all diseases, and Foyes, an Englishman, advocated hydrotherapy 
with great enthusiasm. 

In 1712 appeared a dissertation by Frederic Hoffman, having for title, De aqua medicina 
universalis and showing the marvelous success which attends the therapeutic use of cold 
water; the system of treatment advocated spread rapidly in Germany. 

In Great Britain, Wright, Gregory (of Edinburgh), and especially Currie, all of whom 
attempted a physiological explanation of the action of cold water, gave a powerful impulse 
toward the employment of this method. 

In Italy, Giannini, Vallisnieri, Cocchi became partisans of hydrotherapy. [This was 
about the middle of the last century.] Pomme, who wrote in 1765, was about the only 
French exponent of the new method. Then comes the era of Priessnitz, who, early in this 
century, gave so great an impetus to the water treatment, and stimulated scientific inquiry, 
the results of which are seen in the numerous and able physiological treatises whose authors 
are mentioned in the text. 

20 



ON HYDROTHERAPEUTICS. 21 

employed sweatings followed by cold affusions, then advised wrapping the 
patient in a wet sheet, and, finally, cold baths. He obtained by this mode of 
treatment marvelous cures, which spread his fame far and wide. 

Soon were seen flocking from all parts of Europe sick people seeking 
remedial aid from the healer of Graefenburg, and the village hovels disappeared 
to make way for numerous hotels, which soon became insufficient, so great was 
the number of patients, which kept increasing every day. Moved by this suc- 
cess, the Austrian government shortly appointed a commission which gave 
officially to Pyessnitz the direction of the " hydropathic " establishment, which 
he had founded, and a few years after the institutor of hydrotherapeutics died 
crowned with fortune and with glory. 

Such is the curious beginning of modern hydrotherapy, which, it will be 
seen, owed its popularity to the most gross empiricism. More recently the 
labors of Scoutteten, of Schedel, of Fleury, of Beni Barde, in France; of Chi- 
apponi, in Italy; of Johnson, and of Manby Gully, in England; of Bell and 
Nicanor Rojas, in America; of Roser, of Lersch, of Pleniger, in Germany, have 
given a strictly scientific and medical character to the study of hydrothera- 
peutics, and it is from their contributions that I shall draw material for the 
several considerations into which I now enter. 

PHYSIOLOGICAL ACTION OF COLD. 

Numerous investigations have been made the last few years into the 
physiological action of cold, and of cold water in particular. I shall refer more 
especially to the valuable study of Winternitz. 1 

Whenever you apply a cold substance, such as ice or cold water, to any part 
of the body you determine perturbations in the nervous system, affecting the 
cerebro-spinal axis, and especially the great sympathetic. These phenomena 
are variable as the application of the refrigerant is of greater or less duration; 
if the chilling be of short duration, the tactile sensibility is at first augmented; 
if it be prolonged, all the modes of cutaneous sensibility disappear; a fact 
which has been utilized in the production of local anaesthesia for minor surgi- 
cal operations. If, finally, you cease the refrigeration, the sensibility appears 
anew with a certain degree of hyperesthesia. 2 

1 Winternitz, Die Hydrotherapie auf Physiologischer und klinische Grundiage, Vienna, 
1877. 

2 Cold raises, lowers, or abolishes the excitability of the sensory nerves, and Richardson 
has shown the modifications, varying according to the duration of the refrigeration. When 
the temperature of the skin is a little below 35 ° C. vascularization becomes more active, and 
sensibility more exquisite. When the integument is cooled still more, sensibility undergoes 
diminution, and at eight degrees below zero it is abolished altogether, to reappear as the 
temperature returns to the normal. 

These modifications of temperature have been noted by Winternitz, and with the 
aesthesiometer of Sieveking by Helmholtz, by the determination of the quickness of our sen- 
sory impressions. From 36 C. to 38 C. this velocity is seventy-two meters a second; with 
lowering of the temperature it becomes ten times less. 

These same modifications of sensibility are produced when the cooling body is applied 
to the trunk of a nerve of sensation, and these applications produce first hyperesthesia, then 



22 ON HYDROTHERAPEUTICS. 

But the most profound modification, and that which effects the most happy 
results, from the stand-point of therapeutics, is the perturbation occasioned in 
the vaso-motors. Under the influence of reflex action, 3 following cold water 
applications, the capillaries are seen to become constricted, the peripheral heat 
to diminish, the cutaneous secretion to cease, the skin to become pale, the 
muscular elements to contract, giving rise to the phenomenon known as goose 
sh'n;* at the same time the heart's pulsations diminish, the arterial tension aug- 
ments, as Delmas, of Bordeaux, has shown, and the patient experiences a general 
chill. 

All these symptoms disappear with a rapidity proportioned to the duration 
of the exposure to the action of the cold. To this period succeeds another 
assemblage of symptoms to which has been given the name of reaction, a reac- 
tion which is characterized by manifestations of an opposite kind. The skin 
becomes red, animal heat is raised, the secretions augment, the muscular func- 
tions acquire a new energy, and a quite special sensation of Men etre is 
experienced. It is in this double action of the nervous system that we must 
seek an explanation of the effects of hydrotherapy, whether considered as an 
antipyretic, a nerve tonic, or simply as a means of hygiene. 

I will leave at one side for the present the antipyretic effects of cold water, 
to which I shall return when I shall speak of the treatment of fever by cold 
baths, and I shall at the present time limit myself to the effort to set clearly 
before you the results which may be obtained in nervous diseases from the 
double physiological action above mentioned. 

ACTION ON THE NERVOUS SYSTEM. 

In order that the functions of the nervous system may be accomplished in 
a regular manner, there must be not only complete integrity of all the constitu- 
ent parts of that system, but it must receive a uniform and sufficient supply of 
normal arterial blood. When one of these conditions is at fault immediately 

a period of complete anaesthesia. The experiments of Waller, of Rosenthal, of Eulenburg, 
of Weir Mitchell, etc., are very instructive and convincing. (Richardson, "Action of 
Extreme Cold on the Nervous System," Medical Times, vol ii., 1825. Winternitz, op. cit. 
Waller, On the Symptoms produced by the Application of Cold to the Sciatic Nerve. 
(Arch. Gen. de Med., 5th series, vol. xx., p. 346, 1862.) Eulenburg, Lehrbruch der Func- 
tionnellen Nervenkrankheiten, Berlin, 1871. Weir Mitchell, Injuries of Nerves and their 
Consequences, Philadelphia, 1872.) 

3 Edwards, Brown-Sequard and Tholozan, and Vuipian have shown that when the hand 
is plunged into cold water the temperature of the other hand is lowered or elevated. Brown- 
Sequard has, moreover, remarked that the reflex phenomena determined by the local applica- 
tion of cold to the skin are produced in a point symmetrical to that where the local 
application was made. Dumontpallier has quite recently insisted upon the study of the 
localization of the aesthesiogenous points of the skin. (Edwards, De l'infiuence des agents 
physiques sur la vie, Paris, 1824. Brown-Sequard and Tholozan, Recherches experimen- 
tales sur quelques uns des effets du froid; Arch. Gen. de Med., 5th series, vol. xii., p. 683, 
1858. Dumontpallier, Lecons sur les actions reflexes; Un. Med., 1880.) 

4 Samkowy has noted the following effects on the unstriped muscles of frogs sub- 
jected to intense cold. During life these muscles contract, but after death they are not 
influenced by cold; a contrary result has, however, been observed in mammals. 



ON HYDROTHERAPEUTICS. 23 

modifications, more or less profound, in the nervous system result. This first 
fact being posited, we may immediately deduce consequences of the most posi- 
tive kind from the stand-point of hydrotherapy, which acts on the nervous 
system, on the circulation, and on the nutrition. 

On the nervous system by the sudden perturbation which it causes in the 
functioning of the sensory and motor nerve apparatus, hydrotherapy reestablishes 
the regular operation of the cerebro-spinal axis; it, moreover, brings into exer- 
cise the vaso-motor centres, and thus produces an equilibrium between the 
functions of the brain and cord on the one hand, and the great sympathetic on 
the other. Moreover, it attenuates the exclusive action of certain local 
affections, which, by reason of reflex influences, become the point of departure 
of important secondary perturbations of the brain and spinal cord, 

By its action on the circulation, which it regulates and renders active, 
hydrotherapy still further modifies in a happy manner the functions of the nervous 
system. Finally, by its general effects on nutrition, 1 by its direct or indirect 
action on the vaso-constrictors and vaso-dilators, on the secretory nerves, and 
lastly on the trophic nerves, cold water stimulates nutrition, promotes the regu- 
lar play of the different organs, and becomes one of the most active agents of 
tonic and reconstituent medication. Under its influence the globules become 
richer in haemoglobin, the oxygenation of the blood more active, and we ought 
to make a capital point of this fact in the treatment of nervous diseases. 

Such is the veritable effect of hydrotherapeutics in nervous affections. I 
know that there has been much discussion as to whether the action of cold 
water were sedative, excitant, or perturbing. Some, with Trousseau, have pre- 
tended that cold water is the best of sedatives; others, as Fleury, have affirmed 
its excitant action ; others, with Bloch, its perturbing action. These are, I 
opine, trivial questions, for according as you consider the effects of cold water 
during its application, or after its application, you observe opposite symptoms, 
and that it may be at one time perturbing, at another exciting or sedative. 

MODES OF APPLICATION. 

It is not enough to know the physiological or therapeutical effects of cold 
water, you must understand the conditions to be fulfilled in order to obtain the 
most favorable effects. I am, then, going to enter somewhat into details which 
I believe are of importance, for I have seen physicians prescribe hydrotherapy 
without insisting either on the mode of application, or on the duration of the 
douche, or on the temperature of the water. It is necessary, on the contrary, 
that you should carefully determine all these points in your directions, and that 
you should not leave, as is often done, to persons who are strangers to the heal- 
ing art the management of the hydrotherapeutic treatment. 

1 Kund has experimented on the influence of cold in cases of poisoning by strychnia. 
Frogs poisoned by this medicament, he placed, some in water at 34° C, others in very cold 
water. The muscles of the former very speedily returned to their state of physiological 
relaxation, those of the latter, exposed to a low temperature, kept their tetanoid state a long 
time. The same experiments have been repeated in cats with like results. (Kund, Gaz. 
Med., 1857.) 



24 ON HYDROTHERAPEUTICS. 

The means of application of cold water are numerous; these may be 
arranged in three distinct groups: In the one the water is delivered under 
high pressure, in the second there is no pressure, in the third the applications 
are made to the naked body by means of cloths or sponges. I shall then speak 
of three modes of application— douches, baths, and lotions. 

DOUCHES. 

Douches are by far the most employed. They are divided into a number 
of varieties, which depend on the apparatus by which they are administered. 
Thus we have the douche en pluie, or shower bath; the douche a colonne, in which 
a column of water is let fall upon the body; the douche a lame concentrique, in 
which three or more concentric streams are directed on some portion of the body 
surface; the douche en nappe, in which the water comes in sheets; the douche en 
cercle, in which a circle of jets plays upon the patient; the douche en jet mobile, 
in which a varying direction is given to the jets. I need not occupy much of 
your time with a consideration of these douches; you are familiar with them all. 
In the shower bath the douche is applied by means of a large globe sprinkler 
(po?nme d'arrosoir) ; in the douche a colonne the water descends with some force 
by a circular opening; in the third variety the globe sprinkler, instead of being 
pierced with a multitude of holes, has several circular chinks through which the 
water pours; in the douche en nappe, the watering globe has the form of a bell; in 
the jet mobile a tube of leather or caoutchouc enables one to give a varying direc- 
tion to the stream. The most used of these douches are the douche e7i pluie and 
the mobile /^.douche. 

In general, the stronger the pressure of the water, the less painful the sen- 
sation of cold. At the same time care is needed in the management of the 
pressure, which, when too violent, produces painful traumatisms. In the shower 
bath the douche strikes more especially the upper part of the body, and you 
ought to avoid, save in exceptional cases, douching the head. As for the 
douches e-n jet (the jet sprays), you can make use of different attachments which 
modify the form of the jet, and give the full jet or the broken jet, which may be 
directed, according to circumstances, on different parts of the body. 

It remains for me to say what should be the temperature of the water, 
what ought to be the duration of the douche, what preparation the patient 
should make before, what he should do after, the douche. 

As far as the temperature is concerned, the douche may be cold, it may be 
tempered, or it may be alternately cold and warm. The colder the douche the 
more intense the reaction, the more painful, too, the application of the douche. 
So in very susceptible subjects, and those who experience under the influence 
of cold a painful sensation of cardiac constriction and of suffocation, it is better 
to have recourse to tempered douches. In administering these douches a jet of 
cold water and a jet of hot water are turned by means of stop-cocks into the 
douche apparatus, and you can at your pleasure vary the temperature of the 
douche. Ordinarily at the commencement of the douche the water is tempered 
to 25 C. (77 F.), and is lowered during the douche so that finally it is not more 
than io° C, or 15° C. (50 F. to 59 F.). 



ON HYDROTHERAPEUTICS. 25 

In the douches alternately hot and cold a much more active physiological 
reaction is obtained. In the so-called " Scotch douche " you begin with a 
douche of the temperature of 30 C. (86° F.), and gradually rise the tempera- 
ture to 50 C. (122 F., which is about as hot as can be borne), then you give 
immediately a douche about as cold as ice. There is another kind of alter- 
nating douche in which a succession of warm and cold douches is given to the 
patient. 

DURATION OF THE DOUCHE. 

The douche ought always to be exceedingly short. You have just been 
told that the favorable results of hydrotherapeutics are due to the double action 
on the nervous system ; to obtain this double action the impression of cold 
must be of short duration. As a general rule its duration should not exceed 
thirty seconds, and the first application of cold douches ought not to exceed 
ten or fifteen seconds. 

PREPARATION FOR THE DOUCHE. 

There are certain rules which should govern the patient before, during, 
and after, the douche. The greater the difference between the temperature of 
the body before the douche and that of the water, the more active the reaction 
will be. It has therefore been advised to cause the patient to take vigorous 
muscular exercise before the douche, in order to induce some degree of sweat- 
ing. In our great gymnastic establishments, where the happy idea of douche 
compartments for the public benefit finds realization, it is at the moment of 
greatest muscular activity that the douche is taken. 

This important condition, to have the skin in a state of prespiration, in 
order to derive from cold douches all their desirable effects, is little known, not 
only to the public, but also to physicians. Does not everybody in fact maintain 
that a cold bath taken when one is sweating is a bad thing, and that it is to this 
cause that are due the evil effects which sometimes follow the free external use 
of cold water ? I believe this to be a complete mistake ; and if we occasionally 
see congestions of the lungs follow a cold plunge, it is more probable that 
the individual was chilled before the bath was taken, than that the pulmonary 
congestion resulted from the bath. 

Elsewhere we see, as a medicinal measure, a disposition manifested to 
favor as much as possible this state of sudation by exercise and artificial means. 
As artificial means, in Germany they make great use of the dry blanket, the pa- 
tient being enveloped in several blankets thoroughly tucked around him, and 
kept in the hot, dry, sweating room, or subjected to a powerful vapor bath till 
a state of free perspiration is induced; then the wrappings are removed and a 
cold douche is administered, or he is immersed is a bath of cold water. The 
Russian bath, so much in use among a great many nations, and of which we 
possess in Paris a very complete establishment, the Hamman, is based entirely 
on this double action of heat and of cold water. 

During the douche the patient ought, as Beni Barde recommends, to sup- 
press, as much as possible, strong contractions of the muscles, and keep a firm 
hold of the bar for support. The respiratory distress is mitigated by freedom 



26 ON HYDROTHERAPEUTICS. 

in outcries. In the event of congestive tendencies to the head or to the 
uterus, it is well to take a warm foot-bath, or douche the lower extremities with 
warm water, after the cold douche. 

IMMERSIONS. 

When remedial effects are sought from immersions, the patient either takes 
a single plunge into cold water, which should be of sufficient depth that the 
whole body may be immersed, then immediately rubs himself dry till the skin 
glows, or he remains several minutes in the bath: the latter course is recom- 
mended when an antipyretic effect is desired. 

Partial baths are often beneficial, such as foot-baths, sitz-baths; those with 
running water, furnished with implements for local douching, are preferable. 

AFFUSIONS AND PACKING IN THE WET SHEET. 

Affusions consist in pouring cold water on the naked body of the patient, 
or in what is called the wet pack. Wrapping the patient in wet blankets is a 
very active hydrotherapeutic method. It has this advantage, that it may be 
employed in all places, and without having recourse to the quite complex ap- 
paratuses just described. It is, however, a painful application, and is by no 
means free from danger. The mode of procedure is simple enough: You 
wrap the patient in a sheet that has been wrung out of icy-cold water, — you 
may apply the wet sheet with the patient standing or lying, and keep him thus 
enveloped ten to fifteen seconds, — then with brisk rubbing with dry cloths you 
try to promote vigorous reaction. This envelopment may be partial; in this 
case it has been advised to leave the wrappings on during the entire period of 
reaction. 

Such are in general the methods of application of cold water. There are 
other modes of using cold from a therapeutic point of view, and I shall now 
speak of applications of ice and pulverizations of ether. 

It has been advised to treat certain neuroses by the application of ice 
along the vertebral column, and in England chorea is much treated by 
this method, and so is hysteria. Charcot has even attempted this method at 
the Salpetriere, the ice being placed for the space of a half hour, then an hour, 
over the ovarian region in hysterical patients. By this means he has observed 
a diminution in the number and intensity of the attacks. 1 

Experiments have been made by Weir Mitchell, and by Richardson, to determine the 
direct action of cold on the spinal cord, the brain, and the cerebellum. 

Cold destroys the vital properties of the cerebro-spinal axis when it is too long ap- 
plied. The first effect of chilling the cerebrum is a brief sedative action. Then phe- 
nomena of motor excitation are developed, sensibility is lessened, and if the application of 
cold is continued, the animal falls into a profound stupor, and surgical operations may be 
performed on hirn without the least movement. This state resembles the hibernal sleep. 

When refrigerant applications are made over the cerebellum of birds, backward move- 
ments are produced of a very marked character, the explanation of which has not yet been 
satisfactorily given. According to some they are due to the cerebellum serving as counter- 
poise to the opto-striate bodies which contain the centres for backward movements. Ac- 



ON HYDROTHERAPEUTICS. 2*7 

» 

A physician of Varsovie, Lublesky, has advised another means of produc- 
ing refrigeration — the application of ether spray over the spinal column. He 
has thus treated chorea. 

Such, gentlemen, are the divers applications of cold in the treatment of 
nervous diseases. In the next lecture I shall treat of electricity in the same 
affections; a subject much more complicated, and which will require much 
more persevering study to master. 

cording to Richardson, the cerebellum is the seat of instigation of forward movements, and 
when its action is suppressed, backward movements take place. 

When cold is applied to the medulla oblongata, the respiratory movements are first 
tumultuous, then they are slowed, and finally cease altogether. (Bourneville, De Temploi de 
la glace; Progress Medical, 1876. Weir Mitchell, Injuries of Nerves and their Conse- 
quences, Philadelphia, 1872. Sur les movements de recul produits chez les oiseaux par 
l'application du froid, etc.; Arch, de physiol. norm, et path., t. i., p. 477, 1868. Richard- 
son, On the Application of Cold to the Cervical Region, for the Reduction of Pyrexia; 
Medical Times and Gazette, March 21, 1874, PP- 3 I2 » 3!3') 



ON MEDICAL ELECTRICITY. 

Summary. — History — New Theory of Electricity — Intensity of the Current — Static and Dy- 
namic Electrical Apparatuses — Physical Phenomena of the Electric Current — Chemical 
Phenomena of the Electric Current — Physiological Action of Electricity — Action on 
the Muscular System — Electro-Capillary Phenomena — Action on the Nervous System 
— Action on the Circulation — Action on Nutrition — Technics. 

Gentlemen: — I shall devote this lecture to the study of electricity, con- 
sidered as a therapeutic agent. 

You are already aware of the use which is made of electricity in the treat- 
ment of nervous diseases, and I desire to acquaint you with the physiological 
facts which are the basis of the therapeutic employment of this remedy. But in 
order that you may the better understand so difficult a subject, I shall refresh 
your memories with certain details of elementary physics. It is not indeed 
necessary that the physician should be a profound physicist (despite the common 
derivation of the words) ; he ought nevertheless to know the general principles 
of physics if he would be successful as an electro-therapeutist. 

From the beginning of the seventeenth century, 1 when Gilbert, physician to 
Queen Elizabeth, first applied the terms electrics to such substances as amber and 
sealing wax, which, when rubbed, attract light objects, this department of physics 

1 It was in 1743 that Kruger, professor at Helmstgedt, first applied to therapeutic pur- 
poses, the precious experiment of Nollet, who, having suspended Du Fay by silken cords, 
and put him in communication with an electric machine, drew sparks from his body. 

In 1744, Kratzenstein, of Halle, published a memoir entitled, "Letter from a physi- 
cist on the use of electricity in medicine," and enumerated the results obtainable in 
paralysis. 

In 1748, Jallabert published a work of considerable size on electricity in its applications 
to medicine. 

In 1749, Abbe Nollet employed electricity in other affections besides paralysis. The 
same year, Francois de Sauvage de la Croix, also gave to the world a monograph on the 
curative action of electricity. 

In 1775, Antoine Van Haen, first physician to Marie Theresa, showed that not only 
paralysis, but chorea was amendable to treatment by electricity. 

In 1779 appeared the work of Mauduit of Varennes, which reported eighty-two cases of 
diseases treated by electricity. 

In 1780, Mazars, of Cazelles, gave one hundred and nine observations of patients 
treated by static electricity. The same year, Bertholon appeared as author of a treatise on 
electricity, in two volumes. 

In 1783, Marat published a memoir on electricity and its advantages in medicine. {a) 



(a) Kratzenstein, Letter of a Physicist on the Use of Electricity in Medicine, Hall, 1746. Jallabert, 
Experiments with Electricity, and Some Conjectures as to its-Causes and Effects; Geneva, 1748. Nollet, Re- 
searches on the Particular Causes of Electrical Phenomena, Paris, 1749. Francois de Sauvage de la Croix, 
On the Treatment by Electricity of Hemiplegia. Mauduit de la Varennes, Memoirs on Electrical Treatment 
as applied to Eighty-two patients, 1779. Mazars de Cazelles, Memoir on Medical Electricity, and the His- 
tory of 109 Cases Treated, and the Most of Them Cured by Static Electricity, 1780. Bertholon, Treatise on 
Electricity of the Human Body in Health and Disease; two volumes, 1780. Marat, Physical Researches on 
Electricity, 1782; Memoir on Electricity, 1783. 

28 



ON MEDICAL ELECTRICITY. 29 

has undergone a progressive evolution. Gilbert's crude discovery was improved 
upon by succeeding physicists, but it was not till the middle of the eighteenth 
century that the first applications of electricity to therapeutics were made. 

In 1743, Kruger, professor at Helmstaedt, utilized, for the first time, in the 
treatment of disease the curious experiment of Nollet, who suspended Du Fay 
by silk cords, put him in communication with a plate electric machine, and drew 
sparks from his body. The year following, Kratzenstein, a physician of Halle, 
cured, by electricity, a woman paralyzed in her little finger. Jallabert, of 
Geneva, in 1748, obtained a much more signal success with a patient affected 
for fourteen years with paralysis of the right arm; the cure was accomplished 
in two months by electrical treatment. Some years later (in 1775), Antoine 
Van Haen, physician extraordinary to Maria Theresa, not only cured paralysis, 
but also treated chorea by electricity. 

From this date works on medical electricity follow with rapidity, and mul- 
titudes of cases are reported where this agent was used therapeutically. Mauduit, 
of Varennes, published in 1779 a report of twenty-four observations. Mazars, 
of Cazelles, relates the history of one hundred and nine patients treated by 
electricity, and among the names of physicians who gave attention to this subject 
at this time, I mention one who obtained a great celebrity in our revolutionary 
records, namely, Marat. Thus far frictional electricity alone was employed, but 
toward the end of the eighteenth century Galvani, and especially Volta, made 
new discoveries in the laws, properties, and methods of employment of this 
agent. 

It was the 20th of September, 1781, that Galvani made his curious experi- 
ment with the frog, an experiment with which you are all familiar; and then 
arose that discussion between him and Volta, which resulted in the discovery of 
the electric pile. 

Galvani maintained that the frog was a veritable electrical apparatus, and 
that all that was necessary was a metallic arc to bring into play this electricity. 
Volta took another view, pretending that the electricity manifested was gener- 
ated in the metallic arc, and the invention of the pile seemed to justify his view. 
At the same time Galvani, in support of his opinion, made some remarkable 
experiments, showing that the simple contact of the frog's muscle with the 
sciatic nerve, without the intermediation of a metallic arc, was sufficient to excite 
contractions. Modern experimental research has confirmed the doctrine of 
Galvani, while at the same time doing justice to Volta. The discoveries of 
these two celebrated physicists were soon utilized in medicine; frictional 
electricity was abandoned, and voltaic piles everywhere came into use. In 1832 
Faraday, by the discovery of induction currents, modified yet even more the 
applications of medical electricity, and the voltaic gave place to the faradic 
battery. 

Till quite recently specialists in electro-therapeutics have been known to 
devote themselves exclusively to some one form of electricity, ignoring all 
others. Thus Duchenne, of Boulogne, looked for remedial efficiency in all cases 
to the faradic current, while Remak, then Legros, and Onimus, recommended 
only the voltaic current. A few, meanwhile, went back to static electricity; thus 



30 ON MEDICAL ELECTRICITY. 

Reynolds, in England, and more recently Arthuis, in France. Of late static 
electricity has been brought prominently into notice by Charcot, and his pupil 
Yigouroux. 

At the present day, owing to a better acquaintance with the subject, we 
have abandoned this exclusiveness in methods, and employ, as best suits our 
purpose, faradic electricity, voltaic electricity, or frictional electricity. 

Moreover it would be a strange mistake to suppose that these electricities, 
of different sources, have different properties, comparable, for example, to the 
properties of three different medicines. 

Electricity, from whatever source we obtain it, is one and the same, and 
the differences which we observe in the various apparatuses, voltaic, faradic, 
and frictional, are resolvable into a plus or minus of quantity and of tension. 

NEW THEORY OF ELECTRICITY. 

Whenever you modify the molecular equilibrium of a body, whether by 
mechanical or chemical action, electricity is set free. 1 Electricity, then, is a part 
of the molecular state of bodies, and is a mode of motion. We have now com- 
pletely abandoned the ancient hypothesis of the existence in all bodies of two 
electricities, called positive and negative electricity, which were regarded as 
fluids, capable of neutralizing each other, and which could be separated by 
chemical action or by friction. It has been experimentally rendered certain 
that electricity is one of the ever-varying modes of force, and the new theory of 
electricity, like that of light, is based on the existence of ether, an imponderable 
fluid, which surrounds and penetrates all bodies; an elastic medium, so to speak, 
in which the atoms are enswathed. By chemical or mechanical action we break 
the molecular equilibrium of a compound chemical substance; certain atoms are 
put in a condition in which there is more ether around them than surrounds 

1 The electric fluid is set free whenever by mechanical or chemical action you produce a 
rupture of equilibrium in the molecular state of bodies. Of late years there has been a 
general abandonment of the old hypothesis that every body is charged with two electric 
fluids, positive and negative, neutralizing each other, but separable by mechanical and 
chemical means. 

Electricity is to-day considered as one of the transformations of force, and like, light, 
there is assumed, as the condition of its existence, an impenetrable ether which bathes the 
atoms of all bodies. 

When you put in contact two bodies whose atoms are surrounded by definite quantity 
of ether, and when you act mechanically or chemically on these two bodies, you break the 
molecular equilibrium, and the atoms of one of the bodies have much more ether associated 
with them than those of the other body. 

Whenever a body is in this condition it is said to be electrized positively, while the 
body that has the least ether is electrized negatively. Hence this definition of electricity: 
Electricity is the difference which exists between the actual quantity of ether which impreg- 
nates the molecules of a body and the normal quantity which it should possess. 

There is only this difference between static and dynamic electricity; the one is the electric 
fluid considered in the state of repose, the other is electricity considered in activity, (a) 



(a) Mascart, Traite d. electricite statique. Ganot, Physics, Rardet. De 1. exposition d'electricite an 
point de vue medical et therapeutique. (Bull, de therap, 1880 t. CI p. 289.) 



ON MEDICAL ELECTRICITY. 31 

other atoms (the conditions of equilibrium being effected by the ether); those 
atoms which possess most ether are electrified positively, those which contain 
a minus quantity of ether are electrified negatively. The new definition then 
reads: Electricity is the difference which exists between the actual quantity of 
ether which impregnates the molecules of a body and the normal quantity 
which it should contain. 

This electricity may be relatively in a state of repose, or in a state of 
activity; hence the division into static and dynamic. But whether static or 
dynamic, electricity has qualities of tension, and manifests resistance which you 
must learn. 

INTENSITY OF THE CURRENT. 

There is a well-known formula which enables us to determine the intensity 
of an electrical current. This formula is represented by the following equa- 
tion: /=£. Here /represents the intensity of the current ; E the electro- 
motive force, which, so to speak, separates the electricities, or drives them apart 
to recombine through the circuit ; R the resistance which results from the 
length and narrowness of the conducting wire, etc. 

For these algebraic signs the Electric Congress, held in 1881, substituted 
names which it behooves you to learn, for these names now form part of the 
nomenclature of medical electricity. 

The name Volt is given to the unit of electro-motive force, represented in 
our formula by E. To the unit of resistance (R) the name Ohm is given. The 
name ampere is applied to the unit of intensity (I). A current of Volt passing 
in an Ohm (that is, the unit of electro-motive force acting on the unit of resist- 
ance) gives a unit of intensity, that is, an ampere. If the ampere is produced in 
a unit of time (that is, a second), you have the unit of electrical quantity, that 
is, a coulon. 

Practically, the Volt or unit of electro-motive force is represented approxi- 
mately by a Daniell's constant cell. As for the unit of intensity, that is, the 
ampere, it is not employed in medicine, being too powerful ; it has therefore 
been divided into thousandths, to which division the name of milliampere has 
been applied. On this basis is effected the graduation of certain batteries, and 
in particular those of Gaiffe. 

STATIC AND DYNAMIC ELECTRICAL APPARATUSES. 

The difference which exists between static and dynamic apparatuses results 
from the tension and from the quantity of electricity which they produce. In 
the frictional apparatus you get but little electricity, but electricity of enormous 
tension ; the dynamic machines, on the other hand, such as the electric piles, 
produce a great quantity of electricity, but of feeble tension ; place these 
batteries, however, in special conditions, and you will obtain analogous effects. 
Observe this spark from an induction machine, compare it with that given by 
this static apparatus of Carre, and you will see that they are of equal in- 
tensity. 

Tension plays the same part in reference to electric currents as pressure 
does in liquids. You will often see a river with a considerable mass of water 



32 ON MEDICAL ELECTRICITY. 

which is incapable of turning the water-wheel of a mill, so feeble is the 
current, while, on the other hand, a mighty rushing brook from the 
mountains shall furnish water-power for an entire factory; this illustrates 
what I have said about pressure in liquids. It is the same with 
electricity, and while static machines give us violent effects, but ex- 
cessively short, the electric piles give us prolonged effects, but of very feeble in- 
tensity. The faradic batteries are intermediate between these two extremes, but 
before entering upon the therapeutic applications of these different currents, I 
will glance at their action on the economy. 

PHYSICAL PHENOMENA OF THE ELECTRIC CURRENT. 

Electric currents produce first of all physical phenomena of heat and light, 
which are utilized in medicine. The heat action is especially employed in sur- 
gery (for example, the galvano-cautery, which enables us easily and safely to 
perform grave operations). As for the phenomena of light, we have various 
apparatuses which enable us to illuminate by electricity internal cavities of 
the body, and thus diagnosticate morbid conditions. The polyscope of Trouve 
is an example. 

CHEMICAL PHENOMENA OF THE ELECTRIC CURRENT. 

Besides the light and heat, determined by the passage of the electric cur- 
rent, medicine has utilized the chemical phenomena which result. You know 
that when you pass a current into a saline solution a decomposition of the solu- 
tion is affected, and while the acid seeks the positive pole the base seeks the 
negative pole; the first is called the acid pole, the second the alkaline. Anal- 
ogous modifications take place in the living tissues, and on these is based the 
interesting phenomenon of electrolysis. Already in speaking of the treatment 
of aneurisms, I have alluded to the beneficial effects of electrolysis in these 
cases. I shall not revert to this subject now, and shall only refer you to the 
important observations of Professor Le Fort, which go to show how numerous 
and how remedial are the modifications determined in the tissues by constant 
currents. 

PHYSIOLOGICAL ACTION OF ELECTRICITY. 

I come now to the study of the physiological action of electric currents, as 
this plays the most important role in the treatment of diseases of the nervous sys- 
tem. We will examine successively the action of electricity on the muscular 
system, on the nervous system, on the circulation, and finally on nutrition. 

ACTION ON THE MUSCULAR SYSTEM. 

As far as the muscular system is concerned, we know, since the experiments 
of Galvani, 1 experiments reproduced by Matteuci, Marianini, and especially by 
Du Bois Reymond, that there exists a proper muscular current, not only in the 

1 Since the experiment of Galvani, other experiments by Nobili, Matteuci, and Du Bois 
Reymond, have demonstrated the existence of the frog current which is found in the muscles 
of all animals and of man, but which becomes more and more feeble as you ascend the 



ON MEDICAL ELECTRICITY. 33 

muscles of the frog, but of the whole animal series. This current, which has 
been described under the name of frog current, has been explained in 
different ways. Some, as, for instance, Hermann, have invoked (to explain 
the phenomenon) the chemical actions which are all the time taking place in the 
muscles, and in particular those going on in a substance not yet isolated, which 
he has described under the name of inogene; others, on the contrary, like Du 
Bois Reymond, have supported the hypothesis of the electro-motive molecular 
state of the muscular substance, each molecule of the muscle representing an 
element of the electric pile acting upon the neighboring molecules. 

ELECTRO-CAPILLARY PHENOMENA. 2 

All these theories and all these hypotheses which have been in vogue the 
past fifteen years are to-day abandoned, for the question is much more com- 
plicated than was formerly supposed, and the discovery of electro-capillary 

animal scale. In the sa'me individual the muscle gives a current which is the stronger, the 
more important the function of the muscle is destined to be. 

These experiments have, moreover, shown that every point of the longitudinal surface 
of a muscle is positive with relation to every point of the transverse surface. 

Two hypotheses have been made to explain these electric currents in the tissues. 
Hermann and others have contended that it was necessary to invoke the chemical reactions 
which take place in the muscle. Each muscle in its normal state contains a substance called 
inogene, which breaks up into C O 2 , and an albuminoid body myosin, and it is the decompo- 
sition of this body which sets free the electric current. Others, as Du Bois Reymond, have 
advanced another hypothesis, based on the electro-motive molecular state of the muscles. 
These electro-motive molecules are little centres of chemical action, turning their homol- 
ogous sides in the same direction and acting electrically the one on the other. (a) 

2 Becquerel has investigated certain phenomena which he has described under the name 
electro-capillary. He has demonstrated that two solutions of different nature, conductors 
of electricity, separated by an organic membrane or by a capillary space, constitute an elec- 
tro-chemical circuit capable of giving rise to chemical and mechanical effects. This fact, 
applied to the human organism, goes to show that the greater part of the anatomical ele- 
ments present all the conditions of an electro-capillary couple. There exist, then, in our 
bodies, an innumerable number of these electro-capillary couples, giving rise to currents 
which act without interruption during life, and for some time after death. 

Becquerel has studied the current formed by the bones, the muscles, and the 
nerves; and he has described the electro-capillary currents which pass between the blood 
and the muscular fluids. He has shown that the side of the capillaries in contact with the 
arterial blood is the negative pole, and that in contact with the serosity and the tissues the 
positive pole of an electro-capillary couple. In the nervous substance Becquerel has shown 
that the current is directed from the white substance to the gray substance. He has, more- 
over, pointed out that under the influence of electro-capillary chemical effects there is pro- 
duced a phenomenon which he has described under the name of cementation, which consists 
in the introduction into and the departure from the body of certain elements, without the 
body losing thereby in any manner its form. {b) 



(«) Hermann, Untersuchungen uber den Stoffwechsel der Muskel Berlin, 1867. Du Bois Reymond, 
Conference at the Royal Institution of Great Britain (Revue des Cours Sc. No. 3, 1867. Onimus et Legros, 
Traite" d Electricite, p. 100. 

(i>) Becquerel, Phenomene electro-capillaire (Acad, des Sc. de 1867 a 1870).— Legros et Onimus.— Traite d' 
electricite - medicale, p. 117. 



34 ON MEDICAL ELECTRICITY. 

phenomena and currents of polarization has shown us how difficult is the ex- 
planation of the muscular current. As for the electro-capillary phenomena, it 
was Becquerel who first demonstrated their reality, showing us that when two 
solutions of different nature are separated by an organic membrane or a capil- 
lary space electricity is evolved. Our organisms reproduce, in quantity innum- 
erable, the conditions of these electro-capillary phenomena, and it is easy to 
understand the part they play in the living being. As for currents of polari- 
zation, it has of late been shown that when you pass for a certain length of 
time a current through a muscle, if you arrest the current you cause to be pro- 
duced in the muscle a current passing in the opposite direction, and of greater 
intensity; this current has been called the current of polarization. 

These are facts which show us how manifold are the sources of electricity 
in the human body. Moreover, it is a matter of common experience that when 
you electrically excite a muscle (and for this purpose the induced current is the 
best) you determine energetic contractions, and you utilize this action in the 
treatment of muscular paralyses. 

ACTION ON THE NERVOUS SYSTEM. 

The remarks which I have made apropos of the muscular system are ap- 
plicable also to the nervous system, The nerves, as well as the muscles, pos- 
sess a current of their own; the nerve fibrils as well as the muscular are the 
seat of electro-capillary currents; the nervous mass as well as the muscular 
undergoes polarizations. The nerve current has been compared to electricity; 
to-day this comparison is given up; there can be no identity between currents 
of which one (the nerve vibration or "current") is so slow (ten times slower 
than sound), while the other is so rapid. What we now know is that under the 
influence of certain currents, as the faradic, the properties of the sensory or 
motor nerve reappear, and give rise to contractions of the muscular groups to 
which the nerve is distributed. We also know that by the influence of the 
electric current we modify the electric state of the nerve, and thus cause to 
disappear certain neuralgias of the most obstinate kind. 

ACTION ON THE CIRCULATION. 

Electric currents have a marked action on the circulation. Sometimes the 
current acts directly on the blood-vessel, whose contraction it causes; some- 
times it acts on the vaso-motor centres, directly or indirectly, and in this way 
static electricity may produce effects analogous to those of hydrotherapy. 
When we place the patient on the insulated stool, and after having put him in 
communication with the static machine, draw sparks from certain parts of 
his body, we effect a revulsive action on the skin resembling that produced by 
cold; there is first of all vaso-constriction, succeeded by vaso-dilatation, and 
reddening of the.tissues. 

ACTION ON NUTRITION. 

There is a physiological effect of electricity still more pronounced than 
the other effects above mentioned. I refer to the effect of this agent on nu- 
trition. Under the influence of constant currents nutrition is seen to im- 



ON MEDICAL ELECTRICITY. 35 

prove, and the vitality of the tissues is restored with new energy. Although 
we have not any absolutely scientific explanation of this effect on nutrition, it 
results probably from a double action, — direct action on the trophic nerves, 
and on the tissue molecules of the organism, whose vital energy is raised. 

Such are, in brief, the effects which are obtained from electricity, whether 
from a chemical, physical, or physiological standpoint, and to accomplish our 
end we make use of the different kinds of apparatus which I now place before 
you, static, voltaic, and faradic. 

When we desire to modify the cutaneous sensibility and nutrition in 
general we make use of static electricity; when we wish to limit electricity to a 
group of muscles, or when we wish to restore contractility to certain muscles, 
we use the faradic machine; when, finally, we wish to modify the molecular 
state of certain nerves, or give a new activity to certain tissues, we employ 
galvanism. 1 

1 [Here, in the original, follows an exposition by Dr. Bardet, an electrician of Paris, 
of the technique of the various electrical apparatus, static, voltaic, faradic. This part of the 
work is unsuited to American practitioners, and is omitted from the translation. We give, 
in its place, a chapter on the technics of American electric machines, kindly prepared for 
this work by Dr. C. L. Dana, of New York.] 



ELECTRICAL BATTERIES AND THEIR USE. 

Gentlemen : — Despite much that has been said against the value of elec- 
tricity, it is becoming more and more the custom of physicians to equip them- 
selves with electrical batteries when starting out in practice. The number of 
manufacturers of these batteries has lately increased, and. I am informed that 
all of them make and sell many more instruments each year. 

You wish to know where to get the best batteries, what kinds to get, and 
how to take care of them and use them. I will try to say something upon these 
points as briefly as I can. 

Electricity and magnetism are forms of the same force, but they show 
themselves in different conditions and have correspondingly different physio- 
logical and therapeutical effects. 

The three forms in which the therapeutist uses electricity are the static, 
the induced and the galvanic. We have accordingly static electrical batteries, 
batteries generating faradic or induced electricity, and galvanic electrical 
batteries. 

In order to understand the differences in the effects of these batteries, you 
will allow me first to say a word regarding the physical nature of the force, 
electricity, 

We suppose electricity, like light and chemism, to be a mode of molecular 
motion. That hypothesis is not of much use, however, in explaining the ordin- 
ary electrical phenomena: Therefore it is assumed that every substance is per- 
meated with two imponderable fluids. Under ordinary conditions these fluids 
are united and in equilibrium; but by certain agencies, such as friction, heat, 
chemism, etc., they can be separated. Then we have electrical phenomena, 
which we recognize as due to these two fluids, positive and negative electricity, 
that have been separated and are trying to get together again. We assume 
that the condition of electrical equilibrium is that of zero, and that the earth's 
electricity is at zero. Positive electricity is raised above, negative electricity 
pulled below this zero point. All electricity phenomena, I repeat, result from 
attempts of the fluids to become equalized or stable again at the zero point, 
just as all the phenomena of heat result from differences of temperature, and 
those of gravity from differences of pressure. The distance to which the 
electrical fluids are separated from the zero point is spoken of as the difference 
in " potential." This potential corresponds to the term degrees in measuring 
heat. Now, the greater the difference in potential the greater the effort of the 
fluids to return to zero. High and low potentials correspond to high or low 
intensity of heat. Tension is the result of the widely separated fluids striving 
to return to the zero point. Electrical tension is an important characteristic to 
understand, as it has much to do with electro-physiological and therapeutic 
results. When the two fluids, at different potentials, attempt to become equal- 
ized, they pass along certain paths and form electrical currents. Electricity will 

36 



ELECTRICAL BATTERIES AND THEIR USE. 



37 



pass along any substance, but some substances conduct it more easily than 
others, and these are known as conductors. I have here a table showing the 
relative value of different conductors. They have the following resistance, that 
of mercury being taken as i.: 



Mercury i 

Silver o 

Copper o 

Zinc o 

Platinum o 

Iron o 

Gas carbon 43 



Sulphuric acid 47,000 

017 Commercial nific acid 18,000 

018 Sol. sulphate of zinc 288,000 

057 Sol. sulphate of copper 306,000 

092 Dilute acids or salts from 10,000 to 300,000 

099 Human body about same as dilute saline sol. 

Pure water 12,000,000 



The tissues of the human body are tolerably good conductors except only 
the skin. This offers a great deal of resistance, if it is dry, and it is, indeed, 
the main difficulty to be overcome in passing electrical currents through the 
body. 

Those substances along which electricity passes with great difficulty are 
known as non-conductors or insulators. Of these, too, I show you here a list, 
the substances being arranged in accordance with their relative value as insu- 
lators : 

Caoutchouc. 

Silk. 

Glass. 

Wax. 

Sulphur. 

Resins. Shellac. Dry air. 

The electrical fluids may be kept by insulators at different potentials, the 
insulators preventing them from becoming equalized, or reduced to the same 
potential. Electricity in this condition is called static, and it is always at a 
high tension. 

Static electricity has the power of inducing another disassociation of the 
electrical fluids, in other bodies separated from it by intervening bodies. These 
intervening bodies are called dialectrics. The dialectrical bodies are analogous 
in function to the conductors of electrical currents. They are such substances 
as glass, dry air, gutta-percha, etc. 

There are certain electrical terms which I wish to explain to you: 

The quantity of electricity is the amount of electricity in a given body or 
on a given surface. The electro-motive force is the force which disassociates the 
two fluids, putting them at different potentials; electrical current results. 

The working-power or current strength is the term used to express the 
capacity of the separated fluids to overcome resistance in their attempts to 
reach equilibrium or equalization again. 

This working-power or current strength naturally is in proportion to the 
strength of the electro-motive power which is constantly disassociating the 
fluids and generating the current. If, however, as is always the case, the elec- 
trical fluid meets resistance in seeking equilibrium, the resistance diminishes its 



38 ELECTRICAL BATTERIES AND THEIR USE. 

working-power or current strength. Hence we have a common formula known 
as Ohm's law. 

Electro-motive Force. 
Current Strengths 



Resistance. 

As I have said, all bodies offer some resistance to electrical currents, and 
it is important to have some standard unit of resistance for the sake of com- 
parison. Such standard unit has been adopted, and is called an ohm. It is the 
resistance offered to a current by a certain piece of wire of definite size and 
length. 

A volt is the unit of electro-motive force, i. e., it represents the force which 
will generate a certain amount of electricity in a second of time. A Daniell- 
cell is of about one volt strength. 

A weber (or ampere, as it has been lately called) is the unit of working- 
power or current-strength. It is the current-strength produced by one volt of 
electro-motive force working against one ohm of resistance. 

The coulomb is the unit of quantity and is the quantity of electricity given 
by one weber in a second of time. 

I have gone over the foregoing points very briefly, and have left out much 
in the way of explanation. Sufficient has been said, however, I trust, to render 
somewhat clear the discussion of the therapeutical and physiological effects of 
electricity which we take up now. The main things to be remembered in con- 
nection with the practical properties of electricity are that it shows itself in 
different quantities and at a different tension. You can, if you wish, forget all 
the other things about electricity, and certainly I want you to forget many of 
the ancient terms which have confused the subject. The terms density and 
intensity, for example, can be ignored. 

All medical batteries depend for their efforts upon the quantity of elec- 
tricity generated, the tension or difference of potential of the electrical force 
generated, and the variations in the duration or strength of the currents. 

We come now to the practical subject of the different medical batteries. 

There are three kinds: The static, the faradic or induced, and the galvanic. 
Recollect, if you please, that the phenomena in all depend upon the difference 
of potential in the same hypothetical electrical fluids. 

The Static Electrical Batteries, used for medical purposes, are all modifica- 
tions of the Holtz electrical machine. They consist of two (or more) circular 
discs of glass, one revolving, the other stationary, the latter being perforated 
with windows. The electricity is generated first by friction. The electrical 
plate then induces electricity upon its neighboring plate, from which lattter it 
is conducted off and collected in Leyden jars that hang upon the two prime 
conductors, the negative to the other. P^or medical purposes the battery is 
supplied with an insulated platform upon which the patient sits. The elec- 
tricity, as it is generated, is conducted from one prime conductor to the platform 
and dispersed over whatever is upon it. The patient becomes covered, as it 
were, with a layer of electricity which is at a very high tension, and is con- 
stantly trying to escape and find its equilibrium. If the patient sits quiet and is 



ELECTRICAL BATTERIES AND THEIR USE. 



39 



not touched, he is kept in a kind of electrical bath, the electricity pass- 
ing off at every point in his body and being- continually renewed as 
long as the machine continues 
its work. It does not pene- 
trate the body and exercises only 
a superficial effect upon the cu- 
taneous nerves. If now you 
connect the other prime conductor 
with the earth or a gas-pipe, by a 
chain and then make connection 
between the earth or another gas- 
pipe by a second chain, then 
finally suddenly connect with the 
patient by touching him with a 
brass electrode, you complete the 
circuit. The tense electricity 
bounds to its zero point with such force that it carries off some of the 
metallic parts of the electrode, causing a spark. 





In this way by continually charging the patient and making connections 
upon him, you can draw off sparks from all parts of the body. 



40 



ELECTRICAL BATTERIES AND THEIR USE. 




The trouble has always been with static batteries that they could not 
be made to work in warm weather on account of the moisture of the air. 
But, of late, better instruments have been made, which are covered with a 
glass case and which will act all the year round. 

The machines are improved also upon the original Holtz model. We 
have the Carre, the Toepler-Holtz and other forms. 

Excellent machines are now 
made in this country and it is not 
necessary to import them. J. & 
H. Berge, of New York City, make 
machines, one of which I have 
used for two years and a half, and 
it has never failed me. Queen, of 
Philadelphia, also makes a good 
machine, and Mcintosh, of Chi- 
cago, advertises them. They are 
of various sizes. I believe that 
those with the twenty-two inch 
plates are large enough, but I would not advise the use of smaller sizes. 
The cost varies from $150 to $400. The physician who buys one should be 
supplied with a certain number of electrodes: a medium-sized brass electrode, 
a wooden electrode, a brass-roller electrode, a sharp-pointed electrode with a 
ring and chains, are about ail that are really needed. 

By approximating the prime conductors so that they almost touch, and 
then connecting the outer surface of the two Leyden jars which hang from the 
prime conductors, with sponge electrodes, you can get the static induced 
current, first described by Dr. Wm. J. Morton, who has done much to popular- 
ize the use of static electricity in medicine. 

This induced current has no special peculiarities and is not superior to that 
furnished by faradic batteries. 

If you get a static machine, see that it will generate a spark at least seven 
or eight inches long between the two prime conductors when the Leyden jars 
are on. See also that the connections of the prime conductor and of the dis- 
charging electrodes are well made. Connections with different gas-pipes 
generally answers well. 

Static electricity is at a very high tension, but is small in quantity. Its 
effects, therefore, are chiefly mechanical and — owing to the violence of the 
shocks and the brilliancy of the sparks — psychical. I have found it quite useful 
in the lighter forms of rheumatic and neuralgic pains, in stiffened joints of 
chronic or subacute rheumatism, in sciatica, lumbago, cervico-brachial and 
occipital neuralgias. It may be used also in paralyses with just as good effect 
as the faradic currents and often more conveniently. In hysterical cases it also 
acts well. I believe it to be an excellent tonic and can confirm the opinion of 
French electro-therapeutists, who regard it as producing similar effects with 
hydrotherapy. It is claimed to have a sedative effect in spasmodic conditions, 
but of this I have seen no illustration. It is a ^ood cutaneous and muscular 



ELECTRICAL BATTERIES AND THEIR USE. 



41 



stimulant and counter irritant, and produces effects by acting on the imagina- 
tion, which are just as good as if they were produced in any other way. 

You should treat the patient for from fifteen to thirty minutes at each 
seance, and repeat the seances daily at first. If you wish to lessen the strength 
of the sparks, put one foot on the platform or use a wooden electrode. 

In warm weather have a piece of dry flannel and lay it over the part from 
which you are drawing the sparks. 

In Faradic Medical Batteries, the electricity is produced by induction. 
The chief elements are a cell, and two coils of insulated copper wire. One coil 
is placed around the other, and the outer coil is longer and of finer wire. The 
cell which generates the original current does not generate the electricity which 
is received by the patient. This fact is not generally understood. This original 
current is so arranged that it is being constantly broken and closed again. At 
both break and make, a current is induced in the coiled wire. In the first coil, 
the current of "making" is sent through the battery-cell itself, and not through 
the patient. The current of breaking is, however, sent through the conducting 
cords of the electrodes and thus through the patient. This is called the primary 
induced current, and it is, as you see, made up of a succession of very short 
induced currents, all flowing in the same way; thus the current is always felt 
more strongly at the negative pole than at the positive. Hence by taking hold 
of the electrodes you can at once distinguish between the two. 

Apart from the greater strength of the negative pole, however, we cannot 
say that it has any different physiological effects. 

Every time that a current in the primary coil is induced, it induces a 
secondary current in the outer coil, of an opposite direction. As a result there 
is produced in the outer coil a constant 
succession of to-and-fro-currents, which 
can be conducted through the patient. 
The current of the outer coil is a to- 
and-fro one therefore, and has no posi- 
tive and negative pole. It is stronger 
and has more tension than that of the 
primary coil. It is said by the French 
electro-therapeutists, to have less quan- 
tity and to be different in its physiologi- 
cal and other effects. This is not the 
case, however. Aside from its greater 
tension, or strength it has no therapeu- 
tical properties different from those of 
the primary coil. Some electrical in- 
strument-makers have other coils which 
have a third, and even a fourth, induced 
current. 

I know of no advantage in these, however. All that you want in a fara- 
dic battery is a primary and secondary current, and finally a union of the two, 
which is stronger than either separate. The strength of the different currents 




42 



ELECTRICAL BATTERIES AND THEIR USE. 




is modified by metal tubes which slip over the coils, and which, by interfering 
with induction, weaken the currents. You will observe that the faradic coils 
have in their centre a bar of soft iron, which becomes magnetized and demag- 
netized, and this strengthens the induced currents in the coils. All the 
batteries have, also, a hammer, or spring lever for automatically breaking and 
making the current. 

Good faradic batteries are now made 
by a great many firms. Kidder, the Gal- 
vano-faradic company, Waite & Bartlett, 
Stammers, in New York; Fleming, in Phila- 
delphia; Mcintosh, in Chicago, are some of 
the better known firms. The batteries are very much alike. Most of them are 
run by the Grenet-cell of zinc and carbon, with an acidulated solution of 
bi-chromate of potash as a fluid. 

Kidder uses the Smee-cell. I have recently devised and shown you a coil 
which is made so that it can be run by a single open-circuit cell, devised by 
Haid and sold by Bergmann & Haid, and by Stammers, of this city. The cell 
is a modification of the Leclanche, and is known as an open-circuit cell. The 
coil is small, portable, and can be carried separate from the cell. The advan- 
tages of this form of battery are that it requires less attention^ very rare renewal 
of zincs, and is cleaner and more portable. It is also very cheap, costing from 
$7 to $10. The main things to be looked out for in selecting a faradic battery 
are to have the interruptions by the automatic lever smooth and even, and to 





have the cell one which does not easily get out of order. Some batteries are 
made so that you can have slow or rapid interruptions as you wish, and it has 
even been claimed that in certain forms of paralysis you should only use the 
slow interruptions. I have never been able to find cases where slow interrup- 
tions were of any perceptible advantage, and there are no theoretical grounds 
for supposing that they would be so. If you get a smooth rapidly interrupted 



ELECTRICAL BATTERIES AND THEIR USE. 



43 



current, it will, I believe, answer all the purposes for which a faradic battery is 
intended. 

The small pocket batteries, made on the model of the Gaiffe batteries, are 
convenient for occasional use. But they are not very strong and do not last 
very long if frequently used. 

Electro-magnetic batteries, in which the currents are generated by revolv- 
ing magnets, are not used now, as they are harsh and disagreeable. 




The magnetic battery with roller electrode, devised by Dr. John Butler, is, 
however, quite a useful thing for general faradization. 

The French chloride of silver batteries are apt to get out of order, and I 
have not jnet any one in this country who recommends them. 

As regards accessories, you should get two carbon-pointed, sponge-covered 
electrodes of moderate size; also one very small carbon electrode, and one very 
large one made of annealed brass, covered with sponge, backed with rubber and 
measuring six inches by four. You need also a metallic brush, and one of 
the handles to the electrodes should have an interrupter. In using the 

battery be sure that the electrodes 
are well moistened with warm wa- 
ter. You may add a little vinegar or 
salt to the water if you wish, but 
it is not often necessary. If you 
are very anxious to get contrac- 
tions, or deep effects, lay a cloth 
moistened in the salt water on the 
skin, and let it stay there for 
twenty minutes. Let the current 
pass for some time also, for the 
skin becomes a better conductor 
the longer the current runs through 
it. 

You must remember in seeking for therapeutical effects with the faradic 
battery, that induced electricity is one of high tension and small quantity, like 
static electricity. Consequently its effects are primarily mechanical and coun- 
ter-irritant. You can contract muscles, arouse nerve impulses, effect circula- 
tory changes, and produce important reflex effects. 

Galvanism. Much labor and ingenuity have been spent in devising cells for 




44 



ELECTRICAL BATTERIES AND THEIR USE. 



the generation of electricity. The number in use is large, and I cannot attempt 
to enumerate them all, or discuss their various merits. For medical purposes 
we have now two kinds. The one includes the cells which act constantly when 
the current is closed. The other includes those which act whenever the ele- 
ments composing the battery (e. g., zinc, carbon, platinum, copper, etc.,) are both 
in the common fluid. The former class (known as. two-fluid cells) are not 
touched except to renew water or add some chemical. In the latter (the single- 
fluid cells) one of the elements is always taken from the fluid when the current 
is in use. 

The first class of cells have a much weaker chemical action, and evolve less 
electricity in a given time. Those in medical use are the Daniell cell, the 
Gravity cell, the Siemen's-Halske cell (which latter is a modification of the 
Daniell), and the Leclanche cell, of which there are several modifications. 




The Daniell cell consists of 
(i) A glass vessel containing, 

(2) A sat. solution of cupr. sulphat. 

(3) A perforated cylinder of copper (positive pole). 

(4) A porous clay vessel containing, 

(5) Amalgamated zinc (negative pole) in a solution of 

(6) Dilute sulphur, acid. 

The sulphuric acid acts on the zinc, forming hydrogen. The H is brought 
over to the copper pole, where it unites with the copper sulphate to form copper 
and sulphuric acid. Hence in Daniell's battery the sulphuric acid and copper 
plate are not used up. Only the zinc and sulphate of copper are used. 

Other batteries on the same principle are: 

Grove's, which has nitric acid and platinum, instead of sulphuric acid and 
copper. 



ELECTRICAL BATTERIES AND THEIR USE. 



45 



Bunsen's, which is like Grove's, but has carbon instead of platinum. 

The Gravity cell; it is constructed in various ways, one of which is as 
follows: A cylindrical glass jar is about three-quarters filled with a solution of 
zinc sulphate. In the bottom is placed a piece of copper, to which is fastened 
the end of a piece of insulated wire, and this wire is led up above the edge of 
the jar. Some lumps of copper sulphate are thrown on the copper plate, and 
then a piece of zinc is suspended in the jar, so that its under surface is about 
half way from the bottom of the jar. It is found that the difference in the 
specific gravities of the copper and zinc solutions is sufficient to keep them 
apart, and it is from its being so constructed as to take advantage of this fact 
that the cell has its name. 

The Siemens-Halske cell is similar to the Gravity battery, except that a 
diaphragm of paper-mache is used to still further ensure the separation of the 
two solutions. 

In the Leclanche battery manganic dioxide replaces the nitric acid in a 
Bunsen's battery, and chloride of ammonium solution the dilute sulphuric acid. 

These batteries have a different electro-motive force and different internal 
resistance. 

They may be classed as follows, according to Mr. Delafield (Archives of 
Medicine): 



Low 
Resistance. 


High Electro- 
motive 
force. 


Constancy. 


Little 
trouble for 
short use. 


Little 
trouble for 
long use. 


Gravity 

(very large). 


Leclanche. 


Gravity. 
Daniell. 


Dipping, 

Grove, 

Bunsen. 


j Leclanche^ 

| Gravity, 

Daniell. 



The Siemens-Halske has about the same properties as the Gravity. When 
ordering your cells get large jars, and have them covered so as to prevent 
evaporation. 

The electro-motive force of some of the different cells is about as follows: 



Grove 1.80 volts. 

Bunsen 2. " 

Dipping 2. ll 

Leclanche* ..'. 1.50 " 

Gravity 1. ll 

Siemen's-Halske 1 . " 



Among the second class or single-fluid cells, the zinc-carbon cell, known 
as the Grenet or Stohrer's cell, already referred to, is most used. The Sinee 
cell is also a popular one for generating induction currents. 

If you intend to purchase a galvanic battery, the first question is whether 
you shall get a stationary battery of two fluid cells, of the first class above de- 



46 



ELECTRICAL BATTERIES AND THEIR USE. 




scribed, or a portable battery of the single-fluid or zinc-carbon cells. My ad- 
vice always is to get a portable battery first, because it will supply a larger 

range of needs; then get a sta- 
tionary or office battery later, if 
possible, because they are more 
convenient to use, are more pow- 
erful, and probably will furnish 
better therapeutical effects. 

If you decide to get a porta- 
ble galvanic battery, any of the 
manufacturers whose names I 
have referred to, will supply one. 
In selecting a battery do not get 
one with less than thirty or thirty- 
six cells. It is a mistake to buy 
the cheaper and smaller batteries. 
For although twenty cells will 
answer for most purposes, you 
may at any time find that thirty- 
six cells will do what nothing- 
else will. 
All the portable galvanic batteries made in this country, so far as I know, 
that are of any value, have the zinc-carbon cell. In some the cell is larger, in 
some smaller. The smaller cells do not last quite so long, but the difference in 
current strength is imperceptible. Be sure only that you get a battery which 
is simply made and has good connections, and that there is an apparatus for 
reversing the current. An apparatus for causing rapid interruptions is also a 
useful thing. Hydrostats to prevent the fluid from spilling are not absolutely 

essential. 

I do not advise you to get a combined galvanic and faradic battery, be- 
cause these make the faradic apparatus less portable and you can buy the two 
batteries separately for nearly the same amount of money. Mcintosh, Waite, 
and Bartlett, and the Galvano-Faradic Company and Kidder all make these 
combined batteries. 

If you decide to have an office or stationary battery, your choice will be 
between the Daniell or Siemens-Halske's cell, the gravity cell and the 
Leclanche, or its modification, Bergmann & Haid's. The gravity-cell is the 
cheapest, costing only about sixty cents, the Siemens-Halske cell is perhaps a 
little more durable. The Leclanche has a greater electro-motor force, and 
fewer cells are needed, but it is more expensive. It cannot be used more than 
twenty minutes at a time without becoming polarized and injured. In my own 
office I have used the gravity cell, and with satisfaction. One does not often 
need more than forty Leclanche cells, or more than eighty gravity cells. 

The accessory apparatus for galvanic batteries consists of the same elec- 
trodes above mentioned. This is really all that is generally needed. You can, 
however, supply yourself with special electrodes for the eye, ear, tongue, 



ELECTRICAL BATTERIES AND THEIR USE. 



47 



throat, and urethra, etc. You can also, with advantage, use a very large long- 
electrode for the spine. Electrodes with an apparatus in the handles for re- 
versing the current are also sometimes very useful. 

No galvanometers are yet made in this country which are of very much 
value.* They indicate the presence and direction of the current, but that is 
all. If you wish a cheap galvanometer, buy a compass for a dollar. Get a 
dozen yards of fine insulated copper wire, wind it over a flat spool, and connect 
each end of the wire with your battery; place the compass upon the coil and 
pass the current through it and observe the deviations of the needle. 

For practical purposes, the best way to test the presence and strength of 
galvanic currents is to hold one electrode in the hand and touch the other to 
the forehead. This should always be done before galvanism is applied to a 
patient's head. 




Other accessories to the galvanic battery are a rheotome, which is an instru- 
ment for breaking, and if need be, reversing the current, and the rheostat, 
an instrument for interposing resistances in the circuit and gradually chang- 
ing the current strength. These things are always recommended by electro- 
therapeutists. 

In using galvanic batteries, care must be taken of them to see that the 



* Endelmann now claims to make an absolute galvanometer measuring in mille- 
amperes, which is spoken highly of. (R. Lewandowski, Electro-Technick, Wein, 1884.) 

Gaiffe, of Paris, makes a galvanometer which measures in milliwebers and is not much 
commended. (Op. cit. and R. H. Pierson, Electrotherapie.) 



48 



ELECTRICAL BATTERIES AND THEIR USE. 



fluids are not spilled, or too far evaporated, and connections are not destroyed. 
With ordinary use the zinc-carbon cells last several months, then the fluid has 
to be renewed. With care the zincs will last very much longer. Occasionally 
the elements should be taken out and washed in hot water. 

In using the galvanic current, remember that it is a current of low tension 
and great quantity, and that its effects are much deeper and more potent than 
those of the faradic current. There is a marked difference between faradic and 




PERMANENT OFFICE TABLE, 
For Physicians' Offices, Colleges, Hospitals, &c 

galvanic currents, despite the contrary opinion of Dr. H. C. Wood in his 
classical work on materia medica and therapeutics. If you do not believe it, 
apply the two to the head, rapidly intermitting the galvanic current if you wish. 
The one hurts, but the other knocks you down. Galvanic currents have more 
than a simple mechanical and excito-reflex effect. They produce more profound 
changes in tissue irritability, excite chemical action and induce other electrical 
currents, besides stimulating nerves, muscles and glands. Galvanism is especi- 



ELECTRICAL BATTERIES AND THEIR USE. 49 

ally valuable, as you know, in treating diseases of the internal viscera which it 
alone appears to reach effectively. 

In using galvanism do not forget that the direction of current has probably 
nothing to do with physiological or therapeutical effects. It is the peculiar 
action of the poles, not the current direction that you are to utilize. There- 
fore, always use your large electrode upon some indifferent place, and apply the 
other electrode to the affected part, using the positive pole, with gradually 
increasing and decreasing currents, for sedative effects; the negative pole, or 
alternating poles, with interrupted currents for stimulant effects. 

For deep-lying organs use two large electrodes. The little electrodes 
ordinarily furnished are often very nearly useless. Large electrodes, if needed, 
the polar method, frequent repetition of short or long seances, cautious use of 
current strength, these are the things you should bear in mind in using galvanic 
batteries. 

Galvanism and faradism should be given from two to seven times a week. 
The seances should last, if you wish to give tonic effects, fifteen to thirty minutes. 
When applied to special organs or viscera, three to eight minutes is long enough. 
In chronic cases you should continue treatment for six to eight weeks, then wait 
for a few weeks and begin again. 

§4 



ON THE TREATMENT OF NEURALGIA. 

Summary. — Definition — Pathogeny and Causes of Neuralgia — Influence of the Nervous 
System — Influence of the Circulation — Influence of Diseases of the Blood— Treatment 
of the Neuralgias — Symptom Treatment — Nervous Medicaments — Morphia — Atropin — 
Chloral — Chloroform — Injections of Chloroform — Aconite and Aconitine — Gelsemium 
and Gelsemine — Electricity — Hydrotherapy — Surgical Treatment — Neurotomy — Neu- 
rectomy — Nerve Stretching — Revulsive Medication — Cutaneous frictions — Vesicatories — 
Cauterization — Injections for Local Effect — Acupuncture — Reveilleur de la Fie— Aqua- 
puncture — Galvano-Puncture — Empirical Medication — Phosphorus — Guarana — Sulphate 
of Copper — Pathogenic Medication — Essential Neuralgias—Bromide of Potassium 
— Neurites — Revulsion — Congestive Neuralgias — Aconite — Neuralgias by Anaemia — 
Morphia — Dyscrasic Neuralgias — Chlorosis — Arsenic — Intermittent Neuralgia — Quinine 
— Syphilitic Neuralgia — Arthritic, Dartrous Neuralgia — Treatment of Certain Varieties 
of Neuralgia — Neuralgia of the Foot — Sciatica — Uterine and Vesical Neuralgia — Ileo— - 
Lumbar Neuralgia — Intercostal Neuralgia — Trifacial Neuralgia — Odontalgia — Tic Doul- 
eureux — Migraine. 

Gentlemen: I propose devoting this lecture to that very common affec- 
tion which you will often have occasion to treat, and the therapeutics of which 
you ought well to understand — neuralgia. 1 

Despite the recent extensive researches into the functions of the nervous 
system, we have not yet precise and certain data concerning neuralgia, and 
we are compelled to define this affection by the principal characters 2 which it 

1 It is to Cotugno, in 1765, that we owe the first description of neuralgia. He describes 
sciatic neuralgia, and attributes it to an acrid liquid, which, issuing from the spinal canal, 
descends along the nerve. 

Nevertheless long before the appearance of this work the ancients had certain notions 
concerning neuralgia; Hippocrates, Aretaeus,Celsus described the symptoms; Aretaeus in par- 
ticular knew facial neuralgia; in 1756 Andre gave a good description of this neurosis. 

We must come down to the commencement of this century before we obtain certain 
data respecting the neuralgias. In 1821 Chaussier published his work in which he gives an 
excellent account of neuralgia; then comes the important treatise of Valleix, who has rightly 
insisted on the points douleureux, which are in his estimation characteristic of this neurosis. 
Since then works have multiplied, and we may cite especially, in Germany, those of Noth- 
nagel, Erb, Eulenburg, Rosenthal; in England, the treatise of Anstie; in Belgium, that of 
Vanlair; and in France, those of Vulpian, Charcot, Lasegue, Fernet and Landouzy, Rigal, 
Hallopeau and Martinet, (a) 

2 There have been several definitions given of neuralgia (neuron, a nerve; algos, pain) 
The best known are the following: "Neuralgia consists in a pain, more or less violent, 
having its seat on the tract of a nerve, and disseminated by circumscribed points, veritable 



(a) Dominicus Cotugno, De ischiade de nervosa Commentarius, Naples, 1764; Chaussier, Tableau Synop- 
tique des Nevralgies, Paris, 1822; Valleix, Traite - des Nevralgies, Paris, 1842; Martinet, Essais sur les Nev- 
ralgies, (th. de Paris, 1878, No. 70;) Rosenthal, Beobacht, iiber Neuralgien, 1874; Erb, Galvano therap., Mit- 
theilungen (Arch. f. Klin. Med., Ill, 1867); Northnagel, Storungen bei Neuralgien (Arch, fiir Psych., II, 
1869;) Eulenberg, Functionelle Nervenkrankh., 1871; Anstie, Treatise on Neuralgia, London and New 
York, 1871; Lardouzy and Vulpian, Lecons sur 1. Appareil Vaso-Moteur, second vol.; 1876; Hallopeau, Art, 
Neuralgia in Diction, de Med. Prac; Rigal, Causes and Pathogeny of Neuralgia, 1870, Vanlair; Les Nevral- 
gies. leurs formes et leur traitement, Bruxelles, 1882, 

50 



ON THE TREATMENT OF NEURALGIA. .51 

presents, and neuralgia is still a symptom rather than a pathological unity. 
Without entering here into a discussion respecting the relations of the 
structural diseases of nerves, and the neuralgias, which are veritable neuroses, 
I believe that the symptom known as pain is produced whenever there is 
molecular alteration or modification of sensory nerves. I do not believe in 
"essential " neuralgias, and I am persuaded that when we come to understand 
better the physiology and pathology of the nervous system, that word essential, 
which only conceals our ignorance and uncertainty, will disappear from the 
nosological category. 

What is of importance for us to know from its bearing on the treatment 
of the neuralgias, is the pathogeny and etiology 3 of this affection; on this point 

painful foci, from which stream forth at variable intervals lancinating pangs or other like 
sensations of distress, and on which points, a certain amount of pressure is more or less 
painful." — Valleix. 

The following is from Fleury and Monneret: " Neuralgia is a neurosis of sensibility, 
or, in other words, a painful neurosis; an apyretic disease, intermittent or remittent, irregu- 
lar or periodical, fixed or readily shifting, having its seat in some point of the sensory 
nervous system, cerebro-spinal or tri-splanchnic; principally characterized by a very severe 
pain, which follows the course of the superficial nerve branches, or makes itself felt in the 
deep viscera; is accompanied by functional troubles which vary according to the organ 
affected, and cannot be explained by any appreciable lesion of the nervous tissue." 

Spring thinks that in order that the word neuralgia should be applicable to an}' partic- 
ular case, there should exist two conditions: (i) "the pain should be paroxysmal in character; 
(2) there should be no peripheral or central lesions present." 

As Lereboullet has remarked, neuralgia can only be defined by its symptoms, and 
then we are forced to include under the same definition several distinct affections. 

Axenfeld has given the following definition: " Neuralgia is an affection of the cere- 
bro spinal nerves with this peculiarity, that generally the suffering is, or appears to be, 
limited to the tract of their trunks, branches or ramuscles." 

Anstie thus defines neuralgia: "A disease of the nervous system, manifesting itself 
by pains which, in the majority of instances are unilateral, and which appear to follow the 
coarse of certain nerves, ramify sometimes into a few, sometimes into all the terminal 
branches of those nerves." 

Vanlair has given a different definition, and which is as follows: "An affection whose 
essential symptom consists in a paroxysmal pain, recognizing for its cause a special and still 
undetermined alteration of the elements proper of the cerebro-spinal or ganglionic nervous 
tissue." (a) 

3 Monneret and Fleury have divided the causes of neuralgia into (1) predisposing, (2 
determining. 

Jaccoud classes them into three groups: 1. Intrinsic and primitive modification of 
the excitability of the nerve, from its nucleus of origin to its terminal expansions: 2. extrin- 
sic lesions which act directly or refiexly: 3. Constitutional condition which modifies the 
nervous excitability, generally by the intermediation of the alteration of the blood. 

Rigal classes the causes as follows: 1. General causes (age, sex, heredity)- 2. Causes 
which act directly on the nerves (traumatism, compression): 3. Causes which act through 



(a) Monneret et Fleury, Art Nevralgie du Compendium. Spring, Symptomatologie, t II, p. 80. Lere- 
boullet, Diet, des Sc. Med. Art Nevralgie. Axenfeld, Des Nevroses, Paris, 1864, p. 156. Anstie, Neuralgia 
and Diseases that Resemble it, London, 1871. Vanlair, Op. cit., 1882, p. 5. Axenfeld et Henri Huchard. 
Traite" des Nevroses, p. 34, Paris, 1883. 



52 ON THE TREATMENT OF NEURALGIA. 

I must dwell briefly. I have told you before that in order that the functions of 
the nervous system may be regularly and normally performed, three conditions 
must be fulfilled; there must be: i. Integrity of the nervous system itself, 
cells and fibres; 2. Integrity of the circulation; 3. Integrity of the nutrient 
blood. The sensory system of nerves is no exception to this law, and every 
circumstance, whether connected with the state of the blood or the blood- 
vessels, which modifies these nerves or their centres, may give rise to pain. 
Let us consider each of these conditions separately. 

From the standpoint of the nervous system, all alterations, from the 
profound modifications of neuritis to simple molecular disturbances, may be the 
point of departure of the clinical syndrome described under the name of neu- 
ralgia; wounds of nerves, irritation, compression of nerves, inflammation of the 
neurilemma, neuritis properly so-called, are all so many causes of persistent 
neuralgias. It has even been claimed that rebellious neuralgia is always neu- 
ritis. In my opinion, if inflammation of a nerve sometimes gives rise to a 
stubborn neuralgia, we are not to conclude from this that every persistent 
neuralgia is of inflammatory origin, for some quite obstinate facial neuralgias 
have a different origin. 

As for circulatory troubles, they have a manifest influence on the pro- 
duction of neuralgic phenomena, and in this regard two sorts of neuralgia may 
be distinguished; those which result from want of blood — anaemic neuralgias, 
and those which result from excess of blood — congestive neuralgias, to which 
Gubler first called attention. 

It is to these disturbances of the circulation that neuralgias due to the im- 
pression of cold have been referred, and which are so frequent. Some explain 
them as the result of anaemia of the cutaneous extremities of sensory nerves, 
others as the result of congestion of the nervous centres. The question is more 
complex than one would suppose, and it is impossible at the present day to de- 
cide in one way or the other. Lastly, in certain cases neuralgias originate in 
alterations of the blood. Thus chlorosis, malarial and other blood-poisoning 
conditions, and diatheses, such as gout, may give rise to veritable dyscrasic 
neuralgias. Whether the cause may be changes in the blood, circulatory dis- 
turbances, or some alteration in the nervous system itself, these divers modi- 
fications may affect the sensory nerve in three points of its course; its periphery, 
some part of the main trunk, or its central termination. 

At the periphery, every cause which, through traumatism or atmospheric 
changes, modifies the terminal sensory fibre, may determine a neuralgia which 
shall spread to all the ramifications of the nerve. As an example, I refer you 

the medium of the blood (diathetic and infectious diseases): 4. Causes which act by sym- 
pathy or reflexly: 5. Associated causes: 6. Unknown causes. 

Hallopeau studies the causes under two heads, predisposing and occasional. The last 
are divided into three groups: 1. By direct lesions of the nerves or their roots: 2. By 
lesions more or less remote: 3. By general diseases, (a) 



(a) Monneret et Fleury, Compendium de Med. pratique. Jaccoud, Traite" de Pathologic* Interne, 1 1, p. 
451. Rigal, Causes et Pathogenie de la Neuralgie, p. 12, 1872. Hallopeau, Art, Nevralgie in Nouveau Dic- 
tionaire de med, et de chir. 



ON THE TREATMENT OF NEURALGIA. 53 

to dental neuralgia. A carious tooth produces some alteration of the dental 
pulp, and an irritation spreads along the dental nerve, causing pain in all the 
branches of the trifacial. The annals of medicine are full of similar facts, where 
we see neuralgias persist for years, in consequence of the presence in the tissues 
of foreign bodies which irritate the peripheral extremities of sensory nerves, 
But in order that there may be a painful sensation, a sentient cell must be 
touched ; and this is a point on which Vulpian, Anstie, and especially Vanlair, 1 
have insisted. It is then well understood that if theoretically there exist peri- 
pheral neuralgias, yet in order that there may be phenomena of pain the neu- 
ralgia must be central. 

These preliminaries being settled, we will now enter on the treatment of 
the neuralgias; but in order to pass in review the numerous therapeutic measures 
recommended in these cases, I shall be obliged to establish a certain number of 
divisions. Therapeutic agencies applicable to neuralgia may be classed in 
two distinct groups — the one is addressed to the symptom pain which character- 
izes the neuralgia, this is symptom treatment ; the other is directed to the 
cause of the pain, this is pathogenic treatment. 

Symptom treatment is subdivided into three groups. In the first are placed 
all medicaments which act by modifying more or less profoundly the functions 
of the nervous system, and which are described under the name of hypnotics, 
anaesthetics, analgesics, anti-neuralgics, etc., such as opium, chloral, chloroform, 
and aconite. The second group contains medicaments which act by substitut- 
ing for the pain, another pain, and constitutes revulsive or substitutive medica- 
tion; we place here vesicatories, cauterizations, etc. The third group contains 
substances which experience has shown to have powerful anti-neuralgic proper- 
ties, but the mechanism of whose action is not known, such as turpentine, 
guarana, and sulphate of copper. 

I shall first briefly examine the medicaments of the three divisions of the 

1 Vanlair has given a good physiological and clinical analysis of pain. It de- 
pends on alteration of the normal sensibility but is not itself this alteration. The 
latter is called algesia and pain is but the conscious expression of it. We must, 
he says, distinguish hyperesthesia from algesia; the one is exaltation of sensibility, 
the other is objective pain. In order that there may be pain, according to Vanlair, there 
must be molecular modification in the central ganglia. Neuralgia depends on a change in 
the state of the sensory cell. These aphorisms sum up his views concerning pain: 

I. Notwithstanding the variety of its expressions, pain is one in its essence. 

II. It takes place without the intervention of the terminal apparatus of the nerves. 

III. Painful sensations have not special fibres subservient to their transmission. 

IV. But there exist nerve cells exclusively charged with the exercise of algesic 
sensibility. 

V. Moreover these cells, destined primitively for another function may become in 
certain conditions centers of pain. 

According to Jewell neuralgia has always a central cause while its seat is in the sen- 
sorial tract. The nerve cells of the sensorial tract are modified in their nutrition, and this 
modification is the efficient cause of neuralgia, (a) 



{a) Vanlair, Les Nevralgies, leurs Formes et leur Traitement, 1882, 2d ed.. p. 48. Jewell, Pathology of 
uralgia (Journal of Nervous and Mental Diseases, April, 1877.) 



54 ON THE TREATMENT OF NEURALGIA. 

first group, then the bases of the pathogenic medication, and finally shall take 
up, in order, certain forms of neuralgia and their treatment. 

In the first group stand prominently forth, opium and its derivatives, 
chloral, chloroform, aconitine and gelsemium, electricity and hydrotherapy. 

Opium is undoubtedly one of the means the most employed in the treat- 
ment cf pain in neuralgia, and since the introduction into medicine, by Wood, 
of hypodermic injections, it may be truly said, that it is on subcutaneous injec- 
tions of morphia that we rely most to subdue pain, or at least to obtain tem- 
porary alleviation. 

Is it necessary to make the subcutaneous injection in loco dolenti? Some, 
and Chouppe in particular, have answered this question affirmatively. I do not 
think so. 1/ morphine relieves neuralgia, it is not by any local action on a 
nerve or nerves in a painful region, but by modifying the sensory nerve- 
centre; the anodyne must first enter the circulation and be carried to the 
heart, then sent to the cerebro-spinal axis, before it can have the effect sought. 
The injection then maybe made with equal advantage on the thighs, hips, or the 
fleshy part of the arm, wherever it can be made the most easily. 

You may use Magendie's solution made with cherry-laurel water, or any 
other good menstruum that will not ferment ; the average dose being one or 
two centigrammes. Constantine Paul recommends water that has been boiled. 
If you use common water, mucedines will be sure to form in your solution after 
a few days. Bardet has shown that these aid in the transformation of morphia 
into apomorphia. 

These sub-cutaneous injections, which have supplanted all other modes of 
administration of opiates in the treatment of neuralgias, have one great disad- 
vantage, and only one — the patient easily becomes habituated to them, and 
resorts to the hypodermic syringe, not to obtain relief from pain, but an excita- 
tion which henceforth becomes a necessity. That will be a curious chapter of 
pathology, which shall describe the progress of morphomania in our times ; 
it will show that it has almost always been the case that inveterate and deplor- 
able habits of morphia-taking have had their origin in the use of hypodermic 
injections of that anodyne in the treatment of neuralgia. 

When the hypodermic method was first introduced, Wood, in Great Britain, 
and Behier, in France, employed atropine, but this medicament was soon aban- 
doned on account of the dangers which it presented, and the delirium which 
frequently followed its use. At the same time you may derive benefit from the 
association of the two medicaments, and I recall to your remembrance the- 
formula which I habitually use: 

3$. — Sulphate of atropine o.oi (gr. \). 

Hydrochlorate of morphia o. io (gr. iss), 

Cherry-laurel water 20.00 ( 3 vss). 

M.— 

A cubic centimetre (15 m.) or about a syringeful of this solution con- 
tains half a milligramme (y^ gr.) of atropine, and a half a centigramme ( T ^ 
gr.) of morphia. 



ON THE TREATMENT OF NEURALGIA. 55 

It has been asserted that injections of plain water would relieve pain as 
effectually as injections of morphia, and Dieulafoy has given his support to this 
statement. 1 showed in 1872 that only injections of morphia can be relied upon 
to calm the pain, and that an occasional anodyne effect produced by injections 
of water, is due to distension or rupture of certain muscular fibrillae. 1 

Chloral is one of the best anodynes we possess; it has only one incon- 
venience, that it cannot be administered a great while to the same individual 
without determining by its caustic and irritant action a chronic inflammation of 
the digestive tube. Therefore, I have recommended, in order to obviate this 
inconvenience, to give the chloral preferably by enema; the following combina- 
tion administered per rectum will do good service. Take the yolk of one egg, 
beat it up in a gill of milk, and dissolve one or two grammes of chloral. 
Administered in this way, the chloral, however, in a few days irritates the rectal 
mucous membrane, and must be suspended. 

Certain derivatives of chloral have been proposed as a substitute, and 
croton-chloral has been especially vaunted by Liebreich, Benson Baker, and 
others in Germany and France. Croton-chloral and butyl-chloral are given in 
the dose of thirty centigrammes to one gramme every three hours, till the 
paroxysm disappears; despite the advantages which this remedy possesses in- 
tic douleureux, it is little used in the treatment of neuralgia. 2 

1 The. fact that intense pain is sometimes relieved by a hypodermic injection of water, 
has been attested by a great many observers. Gubler, who has many times witnessed the 
phenomenon, explains it as the result of local infiltration, not only of the cellular tissue, but 
of the histological elements as well. There are degrees of hydration of the tissues, and there 
is a marked relation between this hydration and divers modes of sensibility; witness cases of 
anasarca, in which the infiltrated tissues are relatively insensible, as you will see by testing 
the sensibility over the oedematous parts, and over the surrounding region not invaded by 
the anasarca. The aqueous injections succeed the best, according to Gubler, in those neu- 
ralgias which are called congestive. — Vide Cours de Therapeutique, p. 238, Paris, 1880. 

The whole subject is far from being clear. — Trans. 

' 2 Croton-chloral is obtained by the action of chlorine on aldehyde. By constitution it 
is a chlorated aldehyde of crotonic acid. Liebreich has studied its physiological action; its 
hypnotic effects are due to decomposition in presence of alkalies into bichlorallyline, which 
acts on the brain and spinal cord. 

Croton-chloral is little soluble; it has been employed in the treatment of neuralgias by 

Benson Baker and Skerrit. The latter administered it in the form of pills, in the dose of 30 

centigrams (about 5 grs.) every three hours, and he has thus given five and even six grammes 

a day (75 to go grains). Croton-chloral often causes vomiting. Gray combines croton- 

•rhloral with bromide of potassium in the following formula: 

f 1$. Croton-chlor.. . 1 gr. (gr. xv). 

M. Signa. A teaspoonful every ) Bromide pot... 4 " ( 3 j). 

two hours till the pain is relieved. 1 Water. . , 250 " ( § viij & gr. xv). 

I M. 

Worms employes the following formula : 

1$. Croton-chloral . . 1 gr. (gr. xv). 

Glycerine 60 " ( 1 ij). 

M. Signa. Atablespoonfulevery, £ater . 6c « ( 5 ij). 

Pip.q.s.tofla. 

Syr. simp 25 " ( 3 vi & gr. xv). 

M. 



56 ON THE TREATMENT OF NEURALGIA. 

Chloroform is also in current use in the treatment of neuralgia; it is 
employed almost exclusively locally, occasionally, however, by inhalation in the 
case of neuralgias that are horribly painful. Locally it is used in the form of 
liniment, or injected subcutaneously. Aran, Dupuy, De Frenel, and others, 
advised a long time ago to treat neuralgias locally by compresses wet with 
chloroform, and recently Brown-S6quard has experimentally demonstrated the 
analgesic action of these local applications. But it is especially in hypodermic 
injections that this medicament gives good results. 3 

Introduced into therapeutics by Roberts Bartholow, of Philadelphia, 
then by Doe, of Boston, the usage of subcutaneous injections of chloroform did 
not become general in France till Ernest Besnier made his favorable report. 

Weill counsels the use of the following preparations, potions and pills: 

I£. Croton-chloral 2 grammes ( 3 ss). 

Glycerine 6 " (3 jss). 

Ext. licorice 4 ' ' ( 3 i). 

i y q r ,L p h « ■■ diss). 

M. Sig. A tablespoonful as often as required. 

1$. Croton-chloral, ) 

Licorice powder, > aa 1 gram (15 grains). 

Conserve of roses. ) 
M. F. S. A. pill, No. xx. 
Leoni's potion is as follows: 

1$. Croton-chloral 1 gr, (15 grains). 

Glycerine 16 " 

Aquae lauro-cerasi 16 " (a a ^ ss )- 

M. Each teaspoonful contains ten centigrammes of croton-chloral. (a) 

3 Roberts Bartholow first employed in 1874 these subcutaneous injections of chloroform 
in neuralgia. Stedmann, in 1877, cites eight cases cured by this means. The same year 
Doe, of Boston, treated by this method a case of neuralgia consecutive to zona, but these 
injections did not become general in France till Ernest Besnier made his favorable report 
to the Societe de Therapeutique, November 14th, 1877. 

Dujardin-Beaumetz has experimented with this method, and shown the advantages 
which may be derived from it, and has especially insisted on the general symptoms which 
follow injections of notable quantities of chloroform (from 4 to 10 grammes). Henry Four- 
nier, his pupil, has embodied in his thesis a great number of observations relative to this 
subject, (b) 



{a) Li^breich, On the Action and Use of Hydrate of Croton-Chloral (Brit. Med. Jour., Dec. 20th, 1873). 
Benson Baker, On the Employ of Croton Chloral in Neuralgia (Brit. Med. Jour., 1874). George Grey, On 
the Effect of Croton-Chloral as an Anaesthetic and Analgesic (Brit. Med. Jour., March 24th, 1874). Worms, 
Note on the Action of Croton Chloral (Bull, de Ther. 1874 t 86 p. 447). Martin Skerrit (Lancet, Dec. 2d and 
9th, 1874). Bruennich, Croton Chloral and Prosopalgia, 1874. Weill on Croton Chloral Hydrate (The'se de 
Paris, Dec. 30, 1874). Leoni, Sur le Croton Chloral (Marseille Medicale, April and May, 1877, page 129 
and 25^). 

(3) Roberts Bartholow, On the Deep Injection of Chloroform, in the Practitioner tor 1874. Ernest Bes- 
nier, On Subcutaneous Injections of Chloroform, in Bull, de Therap., t. xcii., p. 433. Stedmann, Eight Cases 
of Neuralgia Treated by Deep Injections of Chloroform (Boston Med. and Surg. Jour., May 24, 1877.) Du- 
jardin-Beaumetz, Des injections hypodermique de chloroforme (Bull, et mem. de le Soc. de Therap., t. v. pp. 
39, 40, 1878). H. Fournier (The'se de Paris, 1878). Duran, Des injections hypodermiques de chloroforme 
Thdse de Paris, 1878). 



ON THE TREATMENT OF NEURALGIA. 57 

I have myself made trial of this method in my hospital practice, and my pupil, 
Henry Fournier, has given the results in his thesis. In order that these injec- 
tions of chloroform may do good, they must be made in the painful region, and 
they must be introduced deeply in the cellular tissue, or muscular interstices; 
neglect to follow this rule has resulted in accidents, and in failure. Plunge 
y©ur needle, then, perpendicularly into the tissues, and carry it as far as the 
guard at the proximal extremity. This mode of treatment is hardly applicable 
to any form of neuralgia except sciatica. 

By these subcutaneous injections of chloroform you may obtain two 
different results — either disappearance of local pain after small doses, or general 
effects, characterized by sleep, when you inject two, three, four, and even ten 
grammes of chloroform, without, however, at any time obtaining surgical anaes- 
thesia. Why do you not obtain complete anaesthesia? It is because chloroform, 
when introduced beneath the skin, is absorbed by the veins and lymphatics, and 
carried to the lungs before entering the arterial system to be distributed to the 
brain and other nerve-centres, and in the lungs it is in large part eliminated. 
What remains uneliminated, and such portion of the vapor of the chloroform 
as, after being expired, returns to the lungs in the air of inspiration, passes into 
the blood of the aortic system, and is carried to the brain, where it has a more 
or less sedative effect, according to the quantity which has escaped the elimi- 
nating action of the lungs. In producing surgical anaesthesia by inhalations of 
chloroform, you practically suppress the principal source of elimination, and 
charge the arterial blood with the toxic agent. 

By the side of these medicaments, and even at their head, we must place 
aconite and aconitia, which give marvelous results in certain varieties of neu- 
ralgia, and especially in facial neuralgia of the congestive form. Experiments 
have shown that aconitia has an action quite special on sensory innervation, 
and in particular on that of the trifacial, and it is this action which Oulmont, 
S£guin, Franceschini, and Laborde have utilized in the treatment of neuralgia. 
You can then make use of the crystallized nitrate of aconitia, and as there 
exist impure aconitais in commerce, you would do well to order the preparation 
of Duquesnel. The granules of Duquesnel contain each one-quarter of a 
milligramme of aconitia; you may give one of these granules every three hours 
till eight are taken in the course of twenty-four hours. 1 

1 I have previously described these medicaments (see vol. II of this series), and shall 
here only treat of the physiological properties of aconitia. 

According to Franceschini and Laborde, aconitine acts especially on the bulbous por- 
tion of the myelencephelon, then consecutively on the great sympathetic, and by their me- 
dium it exerts an influence, more or less profound, on the principal functions of the 
economy. 

Gubler has dwelt on the phenomena that follows aconitia in moderate doses: A half- 
hour after the injection, there are formications over the whole body, a general numbness, 
with tingling, pricking, and smarting in the nose, and end of the tongue, and disorders of 
taste. The tactile sensibility is blunted, torpor supervenes, and the patients feel a 
sensation of a rubber band which tightly constricts their skin. This sensation of general 
anaesthesia is especially felt in the parts innervated by the trigeminal nerve. To sum up. 
the phenomena observed after the administration of the aconitia are as follows: i. A 



58 ON THE TREATMENT OF NEURALGIA. 

Crystallized aconitia is one of the most energetic poisons; and you ought 
rarely to exceed the dose of two milligrammes a day; there are some patients 
even, in whom, owing to their susceptibility to the drug, this dose cannot with 
safety be reached. You ought then to suspend the medicine when the patient 
complains of an uncomfortable sensation of constriction of the mouth and 
eyes, and tingling in the tongue, which are the first toxic manifestations. 
When you cannot obtain aconitia, you can employ the tincture of the root (the 
tincture of the leaves is not to be relied on). Of the common tincture of 
aconite root, you may give ten drops every three hours. [Fleming's tincture 
is much stronger, and should not be given in a larger dose than five drops, at 
least as a commencing dose.] The tincture is much inferior to aconitia, at 
least in the treatment of facial neuralgia. I cannot too highly commend the 
alkaloid in prosopalgia; since I have been in the habit of using it, I have ob- 
tained cures in a great many cases, and always an amelioration. 

In my judgment gelsemium sempervirens 2 and gelsemium merit a place 
far below aconite and aconitia. In the rich, moist soils of Virginia and the 
Carolinas grows a climbing plant with yellow flowers, called the yellow or Car- 
olina jasmine; it is the gelsemium sempervirens. From the root and stalk is 
obtained an alkaloid called gelsemin, discovered by Fredigke. A tincture is 

special modification of sensory innervation, appreciable more particularly in the sphere of 
the fifth nerve. 2. Paralysis of the peripheral extremities of the motor nerves, by an action 
similar to that of curare. 3. Paralysis of the muscles of respiration, then depression of the 
vascular system, and arrest of the heart by a special action on the sympathetic system, {a) 

2 The gelsemium sempervirens, "eclectic febrifuge," botanic family still undecided (re- 
ferred by some to apocynacese; by others to the scrofulariaceae), has long been a popular 
medicine in America. The roots and stalks contain gelsemic acid, discovered by Wormby, 
and gelsemine discovered by Fredigke. The latter is crystallizable. Ringer and Murrell 
have studied the physiological action of the plant. It acts on the muscular system and on 
the heart; produces phenomena of paralysis like curare, and antagonizes strychnia. The 
tincture is powerfully toxic. Dujardin Beaumetz and Eymery have caused the death 
of hares in two hours, by injecting two cubic centimetres of the tincture. Death has fol- 
lowed its use in man. Freeman cites the case of three children poisoned by two grammes 
( 3 ss) of tincture of Gelsemium. Drs. Marin and Courtright have noticed similar cases. 
In a patient of the author two cubic centimetres (about forty drops), administered by mouth, 
caused paralytic symptoms of extreme gravity: 

Almost all authorities who have employed this tincture medicinally, have given it in 
quantities equivalent to twenty drops a day. Massini, however, has employed it in doses 
amounting to 60 drops in the 24 hours. (l>) 



(a) Franceschini, Sur 1. aconitine (Thdse de Paris, 1875). Laborde et Duquesnel, Physiological, Chemi- 
cal, Clinical, and Toxicological Study of Aconitia (Tribune Med., 1881). Gubler, New Researches on the 
Therapeutic Action of Aconitia (Bull, de Then 1864, p. 348 t. 66, and Commentaires du Codex). Dujardin 
Beaumetz, Art. Aconitine, in Diction, de Therapeutique, 1882. Seguin, Report on Aconitia in Trigeminal 
Neuralgia (New York Med. Jour. Dec. 1877. Mary, Du nitrate de aconitine dans les Nevralgies faciales 
(The"se'de Paris, 1880.) 

(6) Isaac Ott, in Philadelphia Med. Times, March 31st, 1877. Cordes, of Geneva, in Jour, de Ther , No. 
5, 1877. Hill in Philad. Med. and Surg. Reporter, Jan. 30th, 1875. Ringer and Murrell in Lancet, 1875, 1876. 
Spencer Thompson, Lancet, 1875. Eymery, Thdse de Paris, No. 362, 1875. Suraszc, Centralb. July, 1875. 
Massini, On the Root of Gelsemium as an Anti-Neuralgic, 1878. Putreyse and Romee, Action physiologique 
de la Gelsemine. 



ON THE TREATMENT OF NEURALGIA. 59 

made from the root, which is given in the dose of ten drops every two hours. 
This tincture has been made the subject of experimentation by Wickham 
Legg, Cordes, of Geneva, Hill of the United States, Spencer Thompson, 
Sidney Ringer and William Murrell, Massini, Suraszc, Roberts Bartholow, and 
others, who have obtained remarkable results in the treatment of facial neu- 
ralgia, and neuralgias especially of the paroxysmal or intermittent form. 

I was the first in France to experiment with this tincture, and my pupil, 
Dr. Eymery-Heroguelle has reported the results in his thesis of graduation 
(August 1877). I obtained certain favorable results from the tincture, but I 
found it an uncertain medicament. Moreover the tinctures were of no definite 
and uniform strength, a fact due probably to the circumstance that in making 
the fluid preparations, all parts of the plant, as well as the roots, were used, or 
possibly because pains were not always taken to obtain the fresh, green root; 
as a consequence the same doses sometimes gave toxic effects, sometimes no 
effect at all. In one of our patients, symptoms of poisoning, of the utmost 
gravity, from the medicinal use of the tincture were noted. Such toxic phe- 
nomena have already been often reported as the result of the free use of this 
tincture, and Hanna, Freeman, and Courtwright have even known death to fol- 
low. I have, therefor, abandoned, in the treatment of neuralgias, the use of 
this drug, as being uncertain and dangerous. These inconveniences may be 
avoided by the use of gelsemin; but this alkaloid is little known, having been as 
yet little studied, and seems much inferior as an anodyne to aconitia. 1 

In the same group of medicaments, we must place electricity and hydro- 
therapy, which modify more or less directly the nervous system. 

Electricity is one of the most active agents in the treatment of rebellious 
neuralgias. In my lecture on " Medical Electricity," I have told you that elec- 
tricity modifies the molecular state of nerves during its application, and sets up 
polar currents in the nerves which prolongs its effect; you need not be sur- 
prised, then, at its beneficial effect in neuralgia. 

You may make use of faradic or galvanic currents; the latter are much 
to be preferred. The negative pole is applied near the nerve-centre, the posi- 
tive pole (which is the truly sedative pole) may be moved over the different 
painful points of the affected nerve. When you are treating tic douleureux, 

1 Numerous fatal cases are on record in American journals of poisoring by gelsemium. 
Thus, Pinkham's case in the Boston Med. and Surg. Journ., for 1876; that of Boutelle, of 
Boston, in the same journal; that of Wormley, in the Amer. Journ. of Pharmacy, for 1870; 
also that of Seymour, in the Therapeutic Gazette, for 1882. Freeman's three cases (referred 
to in the text) occurred in i860; death occurred from taking one or more (in one instance, less 
than one) teaspoonful doses of the tincture. I myself came near dying four years ago from 
the effect of a drachm dose (given through mistake) of Wyeth's fluid extract of gelsemium ; there 
were dimness of vision and double vision, irregular breathing, the most alarming prostra- 
tion, and general muscular paralysis; the use of electricity and stimulants (capsicum, quinine, 
and strong coffee) brought me out of danger in a few hours. The toxicological history of 
this drug is well summed up by Ringer, in the Lancet, for 1878. 

Despite the danger attending the use of gelsemium in large doses, I have found mode- 
rate doses (five to ten drops of the tincture every two hours) a charming remedy in facial and 
especially dental neuralgias. — Trans. 



b'O ON THE TREATMENT OF NEURALGIA. 

your currents should be very mild, and should not exceed three or four milli- 
amperes. In fact, too intense galvanic currents applied in the region of the 
encephalon, determine two effects which we ought to avoid — syncope on the 
one hand, and certain photopsias on the other; it is well, then, to use very light 
currents. 

In the case of sciatica, your current should be much stronger; twenty 
milliamperes, and even more. When treating of electricity in medicine I gave 
you a definition of this term (milliampere), and told you that it was the basis 
on which are graduated all our modern galvanic machines and the only scien- 
tific means at our command of comparing observations relative to the medical 
application of electricity. In the treatment of neuralgia it is necessary to be 
precise as to the quantity, if we would employ electro-therapeutics to ad- 
vantage. 

As for the duration of the current, authorities are far from being agreed, 
some recommending prolonged, others very short sittings. I think, with 
Apostoli, that the duration of the seance cannot be fixed in advance, and that 
the passage of the current should be continued till the pain disappears, or at 
least till some mitigation is obtained. 1 

1 In the treatment of neuralgia, faradic, galvanic, or static electricity may be em- 
ployed. 

Induced currents. — Becquerel was one of the first to recommend the use of very strong 
and rapid currents. He advised the extra current and a wet sponge for electrode, and 
directed to apply the positive pole over the part of the nerve nearest the nerve-centre, 
and the negative pole over the divisions of the nerve; to be passed to and fro. Seances of 
five minutes' duration. 

Duchenne preferred the revulsion method — the painful region to be electrified by the 
metallic brush; a very strong current with rapid interruptions. This is the method of 
"electric fustigation," employed by Tripier. 

Galvanic currents. — Magendie employed electro-puncture with the galvanic current; this 
process is now abandoned. 

Remak, Ramios, Rosenthal, and Meyer make use of a centrifugal or descending 
current; positive pole in the vicinity of the nerve-centre, negative pole at the periphery. 

Onimus also uses the descending current; placing the positive pole over the point ot 
emergence of the nerve, the negative pole over the terminal branches, and passing for 
fifteen minutes a current of thirty elements of Remak. He advises weak currents, but of 
long duration. 

Niemeyer, Tripier, Apostoli, and Bardet, on the contrary, recommend to apply the 
positive pole over the point douleureux, and this is the practice of most electro-therapeutists 
at the present day. 

Static currents. — Arthuis has treated with great success a large number of neuralgias by 
Franklinic electricity. He employs the electric bath, and the electric brush, which is moved 
over the branches of the painful nerve. 

As for the treatment of certain forms of neuralgia — facial neuralgia and gastralgia — 
this is the procedure of Bouchaud, Craddock, Apostoli, and Beard. 

Apostoli employs, in the case of gastralgia — positive polar electrization of the 
pneumogastric: positive electrode over the pneumogastric, negative pole in the hand of the 
patient. 

Bouchaud treats odontalgia by a constant current of ten elements; positive pole on the 
face as near as possible to the painful nerve, negative pole on the antero-lateral region of the 
neck. In a few minutes' time marked relief is generally obtained. 

Craddock has used the constant current with success in neuralgia of the face. Beard 



ON THE TREATMENT OF NEURALGIA. 61 

It is in proceeding in this way that Remak, Onimus, Bouchaud, Craddock, 
Ouspenski, etc., have obtained results that are truly marvelous in the treatment 
of obstinate neuralgias, and especially in neuritis. I, myself, employed as far 
back as 1872 these constant currents in the treatment, more especially, of 
sciatica, and one of my pupils, Dr. Cado, has given the results (often most grati- 
fying) in his thesis. 2 

But if electricity, methodically employed, may mitigate and cure neuralgic 
pains, you should repudiate altogether those " electric " (?) chains, belts, and 
pads, which you see advertised for pain, and especially for the cure of migraine. 
These contrivances are so badly constructed that they are incapable of generat- 
ing any current, and can have no effect at all, unless a moral effect by acting on 
the imagination of the patient. 

Hydrotherapy, like electricity, is one of the most active agencies in the 
treatment of neuralgia. Cold water acts, not only by modifying directly the 
neurility of sensory nerves, but also in promoting healthy circulation and nutri- 
tion, and I know of no better means of arresting a paroxysm of neuralgia, or 
even of preventing a return of an attack than the douche. 

Next in order come the surgical measures, which have a direct action 
on the painful nerve. These are: 1. Neurotomy; 3 2. Neurectomy; 3. Nerve- 
stretching. 

The section of nerves for the relief of neuralgias is quite an old opera- 
has long insisted on the treatment of neuralgias by electricity. In facial neuralgia, galvani- 
zation and faradization rapidly cure, but care and prudence in the use of these means are neces- 
sary. In gastralgia, galvanization gives complete success; in sciatica, ameliorates or effects 
a cure. In the latter malady, Beard recommends to apply one of the poles to the vertebral 
column at the point of emergence of the nerve; the other pole to be moved up and down the 
sciatic nerve, and the current to be especially directed to the points douloureux. ia) 

2 L. Cado, "On the Treatment of Sciatica by Galvanic Currents" Th. de Paris, 
1872. 

3 It was about the middle of the last century that Marechal first proposed the division 
of painful nerves for the cure of neuralgia. Andre has cited cases where Marechal practiced 
neurotomy, but alarmed by the frequent relapses which followed these sections, Andre advised 
to destroy the nerve by means of caustic. 

In neuralgia simple section has now been abandoned to give place to resection, which 
gives much more lasting success, and rules have been laid down for the operation applicable 
to the different resections. Everybody seems now agreed in regarding neurectomy as indi- 
cated in all cases of neuralgia rebellious to all other modes of treatment. It is generally 
recommended to pursue successively the following course, in these desperate cases: 1. 
Simple stretching of the nerve; if this does not succeed, then: 2. Resection of a portion of 
the nerve. {b) 



(a) Beard on the Treatment of Neuralgia by Electricity, in the Practitioner, 1873: and in Beard and 
Rockwell's Medical Electricity. Remark on Galvano-tberapy, i860. Onimus and Legros, Medical Elec- 
tricity, Paris, 1872, Bouchaud on "Constant Currents in Odontalgia," (Bull, de Therap., tome lxxxv. p. 1.) 
Craddock, Trigeminal Neuralgia Treated by the Constant Current, (Practitioner, 1873). Tripier on Electric 
Revulsion, (Courrier Medical, 1870). Apostoli, Treatment of Gastralgia, (Bull, de Therap., 1882, etc. 

(3) Boyer, Traite" des Maladies Chirurgicales, t. vi., p. 334 and 335, Paris, 1822. Otto Weber, Art, Nevro- 
tumie, in Handbuch der Allgemeinen und Speciellen Chirurgie. Tripier, Art, Nevrotomie" in Diet, encyclope- 
dique*. See also Comptes Rendus de la Societe" de Chir. 1882. 



62 ON THE TREATMENT OF NEURALGIA. 

tion, having been performed more than a century ago, by Marechal, in num- 
erous cases. The results are generally temporary and disappointing. Simple 
division of the diseased nerve is not enough, and neurotomy has given place 
to (2) neurectomy, which consists in resection of a portion of the nerve; this 
operation gives permanent cures, the rationale of which is easily understood 
when you recall to mind the way nerves undergo regeneration. This method, 
which is only applicable to regions where the sensory and motor nerves are 
distinct, as in the face, has been signally successful in those painful affections 
of the fifth nerve known as the tic douleureux, and I have a case in point to 
relate which I am sure will interest you all. 

The subject, a patient of mine, was head-clerk in the Hotel Monnaies. 
This man, for three years, had been a sufferer from a most atrocious facial 
neuralgia. All medical means had been employed without any decided ameli- 
oration. Opium, aconitia, electricity, had failed to give more than momentary 
alleviation, they could not prevent the return of the cruel paroxysm; the poor 
man, in despair of a cure, was meditating suicide. Such cases are not excep- 
tional, and you will meet with them in your practice. 

It was an infra-orbital neuralgia — perhaps one of the most painful of the 
facial neuralgias. I advised resection of the upper maxillary nerve, and the 
operation was performed by my colleague and friend, Terillon. The nerve 
was sought at its point of emergence from the foramen, and followed into the 
floor of the orbit; the terminal portion of the nerve, to the extent of two or 
three centimetres, was excised. From the moment that the man recovered 
consciousness from the ether to the present time, now two years, he has had no 
return of the pain, and the triumph of the operation is complete. 

Is the operation always so successful? Unfortunately, no; and many in- 
stances are on record where branches of the trifacial have been resected for 
painful affections, and with the utmost skill and thoroughness, with no result 
but aggravation of pain to the patient and mortification to the surgeon. In 
fact, in these cases the neuralgia was undoubtedly central, and it is easy to see 
that remedial measures which are efficacious when the cause of the disease is 
peripheral, are useless, and worse than useless, when the prosopalgia owes its 
origin to some morbid condition of the encephalic trigeminus centre. 

Neurotomy and neurectomy being, as we have seen, applicable only to 
facial neuralgias, it has been proposed, in cases of mixed nerves, where the 
operation of nerve-section would inflict on the patient a motor paralysis almost 
as distressing as the neuralgia, to resort to another operation, of quite modern 
origin, known as nerve-stretching. 

Practiced for the first time in 1872 by Billroth and Nussbaum, 1 it was not 

1 Nussbaum was the first to practice nerve stretching with therapeutical intent (this 
was in 1872). Billroth also at about the same epoch performed this operation. Fornari 
proposed to give to it the name neurecteny [neuron, a nerve, ekteneia, extension). 

Nerve-stretching has now been performed in England, Germany, America and Italy. 
In France, in 1876, Verneuil applied nerve elongation to the treatment of tetanus. In 1878 
Blum published a memoir on this operation, and Arduzzi made known the results of this method 
in Italy. Several important publications have appeared on nerve stretching; in particular 



ON THE TREATMENT OF NEURALGIA. 63 

until 1876 that this operation found favor with French surgeons, and Verneuil 
was the first in our country to attempt nerve-stretching, and this for traumatic 
tetanus. Since then the operation has become general throughout Europe. 
Chauvel has given us a very complete resume of the history of this operation 
in Europe down to 1881, and from his monograph, we find that fifty-two cases 
of neuralgia had been treated in this manner; in thirty of these cases a perma- 
nent cure was obtained, in twelve there was a decided amelioration, and ten 
were unsuccessful. I have not time to enter into these details, which enable us 
to appreciate at its just worth, this therapeutic measure, and which consists, as 
you well know, in exposing the trunk of a nerve and making more or less 
forcible traction on the same. 

Generally, after stretching the pain disappears, but it is liable to return in 
a short time; yet in a good many cases the benefit obtained is permanent. 

How does this elongation of nerves operate in the alleviation of pain? 
This is a question which we are unable to answer. The more probable sup- 
position is, that the stretched nerves have a reactive influence on the sensory 
spinal centres, an influence which somehow favorably modifies the molecular 
state of the cells; this view receives support from the fact that very powerful 
tractions often do the most good. a 

those of Langenbach, Weiss, Mickulicz, in Germany, Chauvel in France, and Warnots in 
Belgium. 

Nerve-stretching has been applied to a great number of diseases, such as paralysis, 
tetanus, tabes, dorsalis, contractures, convulsive seizures, etc. 

From Chauvel's history we ascertain that in 1881 nerve-stretching had been employed 
in fifty-two cases of neuralgia, as follows: 

Neuralgia of the face 14. 

Intercostal neuralgias 2. 

Neuralgias of the upper extremities 9. 

Neuralgias of the lower extremities 27. 

In these fifty-two cases of neuralgia there were thirty complete cures, twelve cases 
where there was marked amelioration, and ten failures. Twice there were accidents; in one 
case the elongation of the brachial plexus resulted in a hemorrhage from the jugular vein, 
and death fifteen days after from the entrance of air in the veins. In another case Nuss- 
baum witnessed a severe hemorrhage from the popliteal space, after stretching the sciatic. 

In no case, despite the severe tractions, has paralysis followed. (a) 

2 Many explanations have been given concerning the action of elongation of nerves. 

(1) Callender thinks that continued irritation of disordered nerves enfeebles the nerve 
centres. Elongation restores the physiological tone and activity to those centres. 

(2) Verneuil thinks that nerve stretching acts like an incomplete section of the nerve. 

(3) Vogt maintains that it is by acting especially on the neurilemma that elongation 
produces its favorable effects. The neurilemma is the starting point of nerve inflammation, 



(«) Callender, A Case of Neuralgia Cured by Nerve Stretching; Lancet, June, 26, 1875. Nussbaum, 
Aerztliche Intelligeoz blatter, 8, 1876. Duvalt, Thdse de Paris, 1876. Trombetta, Sullo Stiramento dei nervi 
studdi Pathologici e Clinici Messina, 1881. Chauvel On Nerve Stretching (Arch. Gen. de Med. 1881, p. 701- 
710). Langenbuch, Berliner Klin. Woch., i83i. Weiss and Michulicz, Weiner Med. Woch., 1881. Warnot- 
in Jour, de Med et Chir. de Bruxelles, Mai, 1882, p. 438. Pooley, Report of 37 Cases of Neuralgia, of Differe 
ent kinds, treated by Nerve Stretching (Med. Record, 1880). 



64 ON THE TREATMENT OF NEURALGIA. 

Billroth has of late advised to practise what he designates subcutaneous 
elongation of the sciatic nerve. Struck with the distribution of nerves and 
blood vessels in the inferior member, which pass, the former to the posterior 
part of the thigh, and the latter to the anterior portion, Billroth thought that 
by flexion of the thigh on the pelvis he might, without injuring the vessels, 
make energetic traction on the sciatic nerve. This is his manner of proceed- 
ing: The patient being completely relaxed from chloroform, the thigh is 
flexed on the abdomen, and the leg is forcibly extended on the thigh till the 
toes almost touch the head of the patient. This second part of the operation 
demands great care in its performance. The biceps, semi-tendinosus and semi- 
membranosus muscles powerfully resist this movement, and too much violence 
would result in rupture of these muscles or their tendons, or even dislocation 
of the head of the femur. After this flexion and extension, the limb is placed 
in its natural position. 

You have seen me this year perform this subcutaneous elongation in three 
cases. In one, the patient was unable to walk, from an obstinate sciatica, which 
had lasted three months; here, subcutaneous nerve-stretching brought immedi- 
ate, permanent cure. In the other two, the benefit was temporary. You 
remember, too, that it was in arranging the preliminaries for an operation of 
this kind, that we met with that lamentable accident which caused such con- 
sternation among us; I refer to the sudden death from chloroform, whose 
details have been published by the medical press. 3 

Nevertheless, the misfortune that then happened to us does not militate 
against the utility of an operation which has now been so often performed with 
benefit. I believe, then, that in sciaticas rebellious to all therapeutic measures, 
we are warranted in attempting subcutaneous nerve-stretching, which is doubt- 
less a safer operation than that of cutting down on the nerve, as is usually 
done, at the junction of the lower and middle third of the thigh, lifting out the 
nerve with the forefinger, and pulling on it with a force of forty or fifty pounds. 

Having finished the group of medicaments which have a direct action on 
the nerve or nerve-cell, we come to our second group, revulsive or substitutive 
medication, which sometimes gives remarkable results in neuralgia. This group 
comprises a variety of derivatives, from simple rubefacients to the most power- 
ful escharotics. 

First, then, frictions of the painful region have been advised, these to be 
more or less energetic, and, to render them more efficacious, it has been recom- 

and stretching, by causing rupture of blood vessels in the neurilemma, and dislocation of 
nerve fibrils in the same sheath, favorably modifies the inflammatory process, cause of the 
neuralgia. 

In physiological experiments made on animals, it has been shown that a feeble elonga- 
tion produces a real exaggeration of function, and then if the stretching is prolonged with 
still greater force, there follows a diminution in sensibility and movement, which becomes 
permanent if the traction exceeds certain limits, (a) 

3 Vide Comptes Rendus de l'Academie de Medecine, April, 1882. 



(a) Warnots, De l'elongation des nerfs (Jour, de Med. et de Chir. de Bruxelles, Sept. 188a, p. 325.) 



ON THE TREATMENT OF NEURALGIA. 65 

mended to make these frictions with certain cutaneous irritants, and especially 
turpentine. In this category ought to be placed the celebrated remedy for 
sciatica of the policeman of Lyons, which consisted in enveloping the whole 
thigh in a Burgundy pitch-plaster, and which has cured some inveterate cases. 
In England, there is another popular remedy which consists in covering the 
painful limb with flowers of sulphur, and over the whole applying a firm flannel- 
bandage. Of still more general use is the mustard sinapism, which, in some 
cases of intercostal neuralgia, suffices to affect removal of the pain. 

Next comes the vesicant, which is in current practice in the treatment of 
neuralgia. These vesicants may be of different kinds; sometimes the strong 
water of ammonia is applied locally till the cuticle is destroyed; sometimes the 
cantharidal blister, medicated or not with opium, is used. 

In order to obtain relief with these blisters, they should be applied over 
the painful points. In sciatic neuralgia, I have been in the habit of employing 
a long, narrow blister, three centimeters in width and extending the whole 
length of the thigh; this blister is applied, as near as possible, over the course 
of the sciatic nerve. I can, from experience of its utility, recommend this as a 
most excellent mode of treating sciatica. 

In other circumstances, when the neuralgia is more obstinate, it has been 
the custom to resort to cauterizations of greater or less depth. 1 Legroux was 
in the habit of employing sulphuric acid; with a stick soaked in the strong acid, 
he marked out on the painful member the branches of the sciatic nerve. This 
method is a severe one, and is no longer employed; but instead we use the hot 
iron, and in particular the Paquelin cautery; with this cautery, points are made 
all along the nerve. If you prefer transcurrent cauterization, you lightly brush 
the skin covering the nerve or nerves affected, with the Paquelin cautery, heated 
to a white heat. These cauterizations are a powerful means of cure, and, being 
little painful, you can always resort to them when other means fail. 

In order to act still more directly on the diseased parts, it has been pro- 
posed to penetrate to some depth into the tissues, and this is what has been 
realized by acupuncture. 2 You perhaps know the use that has been made of 

1 Cauterization in neuralgia may be. performed in different ways; the moxa, issues 
made by escharotics, the actual cautery have all been used. 

The latter is now the only means employed, either under the form of transcurrent 
cauterization, or punctiform cauterization. The latter {pointes de feu). is the most ancient 
form, and is especially indicated where the pain is limited. In cases where the neuralgia is less 
definitely localized, transcurrent cauterization is the kind to employ. Fleury, Jobert, Valliex 
Seguin, etc., have especially vaunted the latter cauterizations, which have taken the place of 
those made by sulphuric acid, as recommended by Leroux and Dubourg. (a) 

2 In the 17th century two physicians of the East-India Company, Ten Rhyne and 
Rcempfer, made known the manner of performance of acupuncture by the Japanese, but this 
operation was not practiced in France till the year 18 10, and it had for a long time a great 
vogue, owing to the labors of Jules Cloquet and of Dantu of Vannes. 

In the East the physicians who practice acupuncture, call themselves Jecqua in China, 



(a) Treatment of Neuralgia by Transcurrent Cauterization (Union Med. 1847). Valleix, Compendium 
de Med. Pratique, t. VI., p. 186. Seguin, Arch, de Medicine, 1879. Legroux, Cauterizations by Sulphuric 
Acid, (Bull. Gen. de Ther., Sept. et Oct. 1852). 



06 ON THE TREATMENT OF NEURALGIA. 

acupuncture in the far east — it was there that we learned the manner of per- 
forming it; this revulsive method which was much in vogue at the beginning of 
this century, owing largely to the labors of Jules Cloquet and Dantu of Vannes, 
is now altogether abandoned. The principle, however, has been adopted by 
Baunscheidt in that little invention of his called re'veilleur de la vie [life-awak- 
ener], and sold by our instrument-makers under the name of Baunscheidfs 
Dermabiotico?i, which, twenty years ago, excited so much enthusiasm. This 
instrument consists of a bunch of pins which are made to penetrate the skin 
by a spring, and, in order to give a more intense revulsive action, the pins are 
dipped, before using, in croton oil, or in a highly irritant mixture which Baun- 
scheidt devised, of equal parts of oil of black pepper and oil of mustard. 
Baunscheidt's " Life-awakener," with its accompanying oil, has had a great 
celebrity in the treatment of sciatica, but is rather a thing of the past than in 
actual use at the present day. 

A modification of acupuncture, electro-puncture, much used by Magendie 
with galvanic currents in the treatment of neuralgia, has also had its day, and 
is now abandoned. Medical electricity has, however, utilized these acupuncture 
needles in galvano-thermy, which is one of the most powerful revulsive methods 
that I know of, and the excellent effects of which I have seen in my own ser- 
vice and in that of my friend Perier. This operation is performed with the 
condenser of Plante, appropriated by Trouve to medical practice; with a wire 
heated to a red heat by electricity, points are made to the depth of half a centi- 
metre, and some little distance apart, over the tract of the affected nerve. The 
punctures are followed by considerable inflammation, but they often bring the 
greatest relief to the patient. 

I need only glance at another method of making punctiform eschars, a 
horribly painful method, now happily gone out of fashion. I allude to aqua- 
puncture. A filiform jet of water is projected by means of a force-syringe with 
such violence upon various points of the affected nerve that the skin is per- 
forated, often to the depth of several millimetres, in many places. Siredey is 
responsible for the vogue which this method has had. 

Luton's mode of treatment of sciatica is based on the same principle, 
though the manner of application is different. The Professor of Rheims has 
proposed to introduce by the hypodermic syringe certain irritating substances, 
as nitrate of silver, which are injected over the painful spots. The caustic solu- 
tion is made with one part to ten, or five. These irritating injections determine 
an artificial anthrax, which results either in induration of the tissues or in 

and Farittate in Japan. They make use of needles of different metals (gold, silver, steel) of 
extreme fineness, which they insert by means of a conductor. The latter is a metallic tube 
of less length than the needle, enclosing the needle as a sheath; the whole is made to 
penetrate the skin, like the trocar in its cannula; the conductor is then withdrawn, and the 
needle is insinuated more deeply into the subcutaneous tissues by a movement of rotation. 

Acupuncture has caused the cure of a great number of neuralgias, particularly those 
of the face and sciatic nerve, (a) 



(a) Ten Rhyne, Dissertatio de Arthritide, London, 1783. Dantu de Vannes, Traits de 1 acupuncture, 
Paris, 1826. Dujardin-Beaumetz, Art Acupuncture, in Diet, de Therapeutique, 1882. 



ON THE TREATMENT OF NEURALGIA. ffa 

abscess. The partisans of this revulsive procedure claim signal success in its 
use. Out of Luton's fifty cases of sciatica, forty- eight of them are reported 
permanently cured. Rupaner (of Boston), Bertin, Le Dentu, Damaschino, 
Gerin Rose, Dureau, and Angele, all report good results from this operation, 
which Luton, the inventor, has designated as " subcutaneous injections for local 
effect." It cannot, however, be maintained that the operation is altogether 
certain or safe, and troublesome sequelae have resulted, and are likely to result, 
from these irritant injections. 1 In certain cases, instead of making the cauter- 
ization over the painful point, it is made at a distance; and we have seen Jo- 
bert cure sciatica by cauterizing the lobule of the ear. Even at the present 
day, there is sold, under the name of Indian Remedy, an irritating substance 
which is designed to be introduced into the auditory canal, and which is be- 
lieved to act beneficially in the treatment of odontalgia. 

To finish the consideration of the external medication of neuralgia, I 
shall simply allude to massage, or rather what has been described under the 
name of Kinesitherapy. In the treatment of this disease, massage is now 
much used, with its various methods, kneading, pinching, and percussion; 
Schreiber has lately insisted on the advantages of massage in neuralgia and in 
muscular rheumatism. 2 

I have finished the long enumeration of the more important measures 
which constitute symptom-medication, and whose object is the relief of pain. 
It remains for me in order to complete this subject, to speak of the empirical 
means, whose mode of action in the treatment of neuralgia is thus far un- 
known; and I am going to allude to turpentine, phosphorus, guarana, and sul- 
phate of copper. 

Turpentine, 3 which, as I told you, is sometimes used in embrocations and 

1 These injections, first introduced and popularized by Luton, in 1863, are chiefly of 
use in that most rebellious of neuralgias — sciatica. They are made just behind the tro- 
chanter major, towards the inferior border of the gluteus maximus. The injection is made 
into the subcutaneous cellular tissue, and with varying doses of a solution of nitrate of 
silver, one part to five, of which from fifty centigrammes to one gramme may be used at 
one time. In rheumatic sciatica, Gerin Rose injects six cubic millimetres of the following 
solution, which contains one part to fifteen: I£. — Argent, nit., grm. .50; Aquae dest., grm. 
7. M. He seeks the most painful point, which is generally where the nerve issues from 
the pelvis at the great sacro-ischiatic foramen, and plunges deeply the Pravaz needle so as 
to penetrate the cellular tissue into the muscular interstices, in which (providing no blood 
wells up through the needle, making its appearance at the proximal end), after having 
adapted the syringe, he slowly injects, drop after drop, the solution. The second day, a 
phlegmonous tumor as large as the fist forms over the site of injection; this, however, 
rarely suppurates, but disappears by resolution. Gerin Rose has been successful in thirty 
cases, and has witnessed no troublesome sequelae. (a) 

2 Bull de Ther., t. cii. p. 276, April 15, 1882. 

3 It was in England that oil of turpentine was first employed for the "mat iscJiiatiqtie." 
Home, Pleyne and Pitcairn have written in its favor; it was popularized in France by Mar- 



O) Luton, Des injections sous-cutanees a effet local, Paris, 1875. Blosart, Treatment of Chronic Sciatica 
by Injections of Nitrate of Silver (Th£se de Paris, 1872). Angele, Treatment of Neuralgia by Irritating In- 
jections, These de Paris, 1878. 



68 ON THE TREATMENT OF NEURALGIA. 

liniments in this disease, has also been given internally; and Martinet and 
Trousseau have prescribed, in sciatica, capsules of essence of turpentine, six or 
eight to be taken every day. It is possible that some cases of sciatica may 
have been cured in this way, but turpentine readily disorders the digestive 
functions, and is often badly tolerated, hence is little used as an internal 
remedy. 

Phosphorus 4 has been the most often employed in England and America 
in the treatment of neuralgia. This use of phosphorus is altogether empirical, 
and although we have seen that protagon, the proximate constituent of cerebral 
substance, contains a notable proportion of phosphorus, no direct relation has 
as yet been established between the functions of the cerebro-spinal axis and 
the presence in the nervous tissue of a greater or less quantity of phosphorus. 
However this may be, Thompson, in England, and W. A. Hammond, in the 
United States, have highly recommended its use. 

Phosphorus has been given in two ways, as phosphorated oil and as phos- 
phide of zinc. [In this country the pill-form is generally preferred, each pill rep- 
resenting yirj-th grain; one or two of these pills three times a day. — Trans.] 
Phosphorated oil is administered in capsules containing one milligramme of 
phosphorus; beginning with one capsule, and gradually increasing to ten cap- 

tinet in 1818. Large doses, four to 12 grammes (teaspoonful to a tablespoonful), during the 
twenty-four hours are required: 

Teissier of Lyons has obtained good results from turpentine in certain cases of nervous 
cephalalgia (a). 

4 Edwin Sladeking recommends phosphorus in neuralgia, and this is his mode of ad- 
ministration: The full dose should not be more than a twentieth, nor less than a thirtieth 
of a grain, and should be repeated every two hours, the patient being made to take a little 
mucilage before the medicine. After eight doses thus taken, the interval between the doses 
should be increased to four hours, then eight hours, and the medicine should be discon- 
tinued when the total quantity taken equals one grain. If after this the neuralgic pains 
persist, some other treatment must be adopted. 

Ashurst and Thompson have reported eighteen cases of neuralgia treated by phos- 
phorus. Their formulae are as follows: 

1$ Phosphorated oil 6 (3 jss). 

Pulv. acacias 12 (3 iij). 

Spts. menth 1 (gr. xv). 

Water 200 ( § vj and 3 v). 

M. 

1$ Tinct. phosphorus 6 (3 jss). 

Alcohol 4 (3j). 

Spts. menth. 1 (gtt. xx). 

Distilled water 200 ( § vi and 3 v r ). 

M. Sig. Dose: A tablespoonful after meals. (b) 



(a) Martinet, Du traitement de la Sciatique et de quelques aurtres Nevralgies par l'huile de terebenthine, 
Paris, 1827; (Teissier de Lyon, Union Med., Jan., 1864, No. 10). Janneson, On the Use of Turpentine in the 
Treatment of Sciatica; (Edinb. Med. Jour., p. 749, Feb., 1877). 

{b) Edwin Sladeking-, On the Administration of Phosphorus in Neuralgia; (Med. Times and Gazette, 
April 19, 1873). Ashurst and Thompson, Some Observations on the Use of Phosphorus in Neuralgia, Illus- 
trated by Eighteen Cases; (Practitioner, July, 1873). 



ON THE TREATMENT OF NEURALGIA. 69 

sules, three times a day. Phosphide of zinc is an excellent form for adminis- 
tration of this medicament. This phosphide readily undergoes decomposition 
in the presence of the acids of the stomach, yielding up its active principle. In 
connection with a former pupil, Proust, one of the victims of the late Franco- 
Prussian war,T made quite a thorough study of these metallic phosphides, 
which had lately been introduced into therapeutics by Vigier, and our experi- 
mentation showed that we might profitably utilize in medicine many of these 
compounds. Phosphide of zinc is given in pills of four milligrammes (about 
yig-th grain), this represents one milligramme of phosphorus. From one to 
ten of these pills may be given a day. I shall return to phosphorus-medication 
when I come to speak of chronic myelitis; as for its results in the treatment of 
neuralgia, in my experience they have been simply nil} 

Guarana, or paullinia, has been recommended for neuralgia, and especi- 
ally for migraine. This substance, as you are aware, comes to Europe in the 
form of cakes made by drying a paste of the seeds of Paullinia sorbilis. The 
latter is a climbing plant belonging to Brazil, of the family Sapindaceae. 
Besides gum and starch, fatty matters, and tannin, it contains caffeine in notable 
quantity, which latter is the active ingredient. The guarana may be given in 
powder for migraine; dose, one or two grammes stirred into a little water, before 
or during an attack. Caffeine may be given instead, in the dose of twenty-five 
to fifty centigrammes. This medicament has an action which is often decided, 
though of short duration. 2 

Ferreol has of late recommended ammonio-sulphate of copper in the treat- 
ment of stubborn cases of neuralgia of the face. This medicament, whose 
modus operandi is unknown, may possibly act in accordance with Burq's theory 
of metallotherapy. It is given in potion in the dose of ten centigrammes, a 
day, or (what is the better way) in capsules containing two centigrammes; five 
to ten of them being given daily. (The results have not been very favorable.) 

Having finished symptom-medication, and considered successively anodyne, 
revulsive, and empirical modes of treatment, we come to our second part, or 
pathogenic medication. 

You remember that we referred to three principal causes the etiology, or 
rather the pathogeny, of neuralgia; this disease being the result of modifications 

1 In this place tonga deserves mention, a remedy for neuralgia introduced to the profes- 
sion by Sidney Ringer and William Murrell, of London, in 1880 {vide Lancet, March, 1880), 
and obtained from the Fiji Islands. It has long been used by the South Sea Islanders for 
all cases of neuralgia. It is employed in the form of alcoholic extract, in the dose of a 
teaspoonful every six hours. Its effects seem to be very similar to those of guarana. A 
good preparation of tonga is made by Parke, Davis & Co., of Detroit. 

2 Introduced into New England about the year 1870, and long sold at fabulous prices, 
no remedy has given more satisfaction in the treatment of migraine than paullinia, and the 
effects have generally been as lasting as those of any other remedy. The following formula 
by the late Dr. George M. Beard, has done good service: 

I£. Citrate of caffeine, 

Carbonate of ammonia, aa 3 j. 

Elixir of guarana, § j. 

M. Sig. Dose, a teaspoonful. — Trans. 



70 ON THE TREATMENT OF NEURALGIA. 

affecting the integrity of the nervous system, central or peripheral, or of the 
blood, or finally of the circulation. Here, then, are three classes of causes 
which we must pass in review. 

From the stand-point of the nervous system, leaving one side alterations 
more or less profound, and compressions of the nerves, I desire to call your 
attention to two points : first, the predisposition to neuralgias in the 
neuropathic and hysterical ; second, to inflammation of the nerve-tubes or 
neuritis. 

Neuralgia is one of the manifestations of the nervous temperament, and 
it may be affirmed that every nervous person suffers more or less from it. In 
these cases we witness the triumph of the bromides and of hydrotherapy. 
Bromide of potassium (alone or associated with other bromides), cold douches, 
local or general, and suitable outdoor exercise are the most certain methods of 
cure of neuralgias due to neuropathy; electricity, and especially static electricity, 
is a useful adjunct. 

Neuritis is one of the causes of obstinate neuralgias ; it entails atrophy of 
the member, and trophic cutaneous disturbances. The most effective remedy 
for neuritis is revulsion, which has a favorable influence on both pain and 
inflammation. Here all the revulsive methods before alluded to are applicable, 
and especially active cauterizations. To counteract the trophic troubles, you 
should have recourse to galvanism. 

- Neuralgias due to circulatory modifications are of two kinds, congestive 
and anaemic. Congestive neuralgias are especially frequent in the arthritic, and 
are best treated by ergot and aconitia. It is especially in facial neuralgias of 
plethoric persons, with marked congestion of the face, that aconitia is effective, 
and this by a sort of double influence on the circulation and on sensory inner- 
vation. Marino 1 has recently proposed ergotine for these congestive neuralgias, 
basing his recommendation on the known effects of this drug in constricting the 
minute vessels and anaemiating the tissues. I have never used this drug in 
neuralgia, having almost always found in aconitia a heroic and certain remedy. 
In neuralgias from cerebral anaemia, morphia is par excellence the medica- 
ment. It removes pain and provokes a salutary congestion of the sensory nerve- 
centres, which directly antagonizes the cause of the pain. Gymnastic exercises 
and hydrotheraphy are most excellent adjuvants in these cases. 

As for the alterations of the blood, which are the points of departure of 
dyscrasic neuralgias, they are very numerous, and chlorosis deserves the first 
mention. It may be affirmed that every chlorotic girl is neuralgic, and here we 
have an illustration of that grand principle of Hippocrates, sanguis moderator 
nervorum. Therefore, every therapeutic means which shall augment the rich- 

1 Marino, Ergotina per uso Epidermico, nelle cura delle Neuralgia, Palerma, 1877. He 
uses the following solution for injection: 

1$. Ergotine 2 gr. 

Cherry laurel water 10 gr. 

Glycerine 10 gr. 

M. 



ON THE TREATMENT OF NEURALGIA. 71 

ness of the blood, and the proportion of its haemoglobin, is applicable to these 
cases; ferruginous or arsenical medication, baths of compressed air, inhalations 
of oxygen, country air and exercise, hydrotherapy, gymnastics, nourishing food, 
all these remedial measures are indicated. I cannot too strongly urge the use 
of arsenic in these cases of chlorosis; in my experience, the arsenical treatment 
lias been quite as successful as the ferruginous, if not even more so; for arsenic 
acts not only as a reconstituent, but it is a direct modifier of nerve substance. 
Those who have had the most practical acquaintance with the use of arsenic in 
neuralgia are the most emphatic in its praise. 

This medicament may be given in the form of Fowler's solution; dose, 
three to ten drops after meals. [Anstie prefers this form of administration; he 
finds arsenic especially useful in neuroses of the par vagum.] It is also given in 
granules and in pill form. [The combination with quinine, ext. of aconite, and 
strychnine of Dr. Gross, known as Gross' neuralgic pill, is a favorite one in the 
United States.] x 

Certain neuralgias are of malarial origin; here we witness the triumph of 
sulphate of quinine. Marrotte has given us a good description of these febrile 
neuralgias, due to marsh poison. Where there is any reason to suspect any 
pathogenic influence of this kind, you should be particular to ascertain 
whether the neuralgic attack comes on at a fixed hour, in which event you can 
easily and speedily control the affection by a full dose of quinine. You can 
increase the effect of the quinine by combining it with aconite, giving every 
three hours a capsule or wafer containing one-quarter of a milligramme of crys- 
tallized nitrate of aconitia, and twenty-five centigrammmes of quinine; four of 
these may be given each day. 

The diatheses, and in particular, syphilis, arthritism, dartre, have often a 
marked etiological relation to neuralgia. As for the first, you must not con- 
found the so-called "osteocopic pains" with the neuralgic pains, which really 
often exist under the influence of syphilis. These cases demand the ordinary 
anti-syphilitic treatment. 

As for neuralgias of arthritic origin, they are among the most frequent, and 
sciatica and gout are often one and the same thing. The means which succeed 
the best in the treatment of gouty and rheumatic neuralgias are baths, and in 
particular, sulphur baths and vapor baths; the latter are often medicated to 
advantage with turpentine or pine shavings. In rheumatic neuralgias, the 
thermal waters are often successful; those of Plombieres, Bourbonne, and 
especially Aix-les-Bains. In these neuralgias we may employ cyanide of zinc, 
proposed by Luton, and especially salicylate of sodium. 

The dartrous neuralgias are readily amenable to the arsenical treatment. 2 

1 Vide Cohen on "Arsenical Treatment of Neuralgia" in Jour. Med. de Bruxelles, 
1864. Barilla, in do., for 1863. Vanlair, The Neuralgias, then Forms and Treatment, etc., 

1882. 

2 Marrotte. " Febri-nevralgies de l'isthme du Gosier," Bull. Gen. de Therap., 1874. 
Abbot, "Sciatic and Facial Neuralgia Treated by Salicylate of Sodium," Boston Med. and 
Surg, Journ., July, 1879. E. Labbe, " Nevralgies traites par le Salicylate de Soude," Soc. de 
Therap., Paris, Feb. 9, 1881. Lagrelette, " De la Sciatique," T/i. de Paris, 1869. This 

writer advocates strongly vapor baths and hydrotherapy in sciatica. 



72 ON THE TREATMENT OF NEURALGIA. 

Such is a somewhat curt summary of the principal indications of the patho- 
genetic treatment of neuralgia. I must now briefly consider the therapeutics of 
certain forms of neuralgia, and for convenience of arrangement will begin with 
the foot and end with the head. 

Plantar neuralgia is one of the most painful of neuralgias, and incapacitates 
the sufferer from walking or standing. It is especially gouty and rheumatic 
patients that are affected in this way. This neuralgia is often rebellious, last- 
ing months and even years. You have seen a good example in our wards; I 
allude to a certain female, who, in consequence of rheumatism following an 
accouchement, has been for six months confined to her bed by plantar neuralgia. 
What has seemed to succeed best in her case has been the application of strong 
tincture of iodine, and hot sulphur foot-baths. 

I shall not dwell long on sciatic neuralgia, 1 which has been often taken as 

1 Sciatic neuralgia (sciatic rheumatism, sciatica, femora-popliteal neuralgia) is charac- 
terized by the presence of pain along the course of the sciatic nerve, and its branches. 
More frequent in the male than in the female, it has its seat indifferently on either side. It 
may be caused by wounds, contusions of the nerve, the impression of humid cold, neuritis, 
the presence of abdominal, pelvic, stercoral tumors, displacements of the womb, 
pressure of the fcetal head during accouchement, bony alterations of the neighboring parts, 
spinal meningitis; according to Bailly, Everard Home, Founier, blennorrhagia may be a 
cause. 

Sciatica is almost always single, at the same time it may be double. Worms has 
pointed out the frequency of these double sciaticas in diabetic patients, but more generally 
these double sciaticas are rather the painful expressions of affections of the spinal cord. 

Rarely the disease has a sudden commencement. Generally it announces itself by 
numbness, heaviness, a sensation of cold in the entire limb, or in certain limited parts; then 
after a variable time there is an outburst of pain, which may occupy different branches of the 
nerve (genito crural, cutaneous femoral branches of the lesser sciatic, articular branch of the 
great ischiatic and peroneal, internal popliteal, short saphenous or posterior tibial, or lastly, 
the terminal plantar nerves); it may remain limited, or be progressively diffused over many 
branches. 

It is dull, continuous, contusive, accompanied with formications and with tingling; it 
presents also paroxysms, or exacerbations. Under the influence of walking, muscular exer- 
tion, heat, or without any known cause, lancinating pangs are experienced radiating along 
the course of the nerve; the patient can often mark out with his finger the tract of the painful 
nerve. These pains are exasperated] by pressure, by movement; the patient instinctively 
seeks repose and avoids all muscular contractions, lying on the opposite side from the pain. 
In some cases the patients feel in the bones and joints a sort of deep and piercing pain, 
which, according to Jaccoud, indicates an intra-vertebral origin of the neuralgia. When 
there are, moreover, alterations of sensibility, consisting in formications, tingling, aching 
sensations in the back, girdling pains {douleurs en ceinture), the neuralgia has for its origin a 
lesion of the cord or meninges acting on the posterior columns. Apart from the attacks, 
some patients suffer little and are able to work. Others become incapacitated, walk with 
difficulty, limping, or even are compelled to cease walking altogether. Besides these pains, 
disorders of the cutaneous sensibility have been noted, and Hubert Valleroux, in his thesis, 
describes sensory troubles (pertaining to tactile sensibility, sensibility to temperature, etc.), 
especially occurring in the posterior region of the thigh, four or five finger breadths below 
the popliteal space; atrophy of the affected member has been noted; a slow muscular atrophy 
in the pure neuralgias, a more early atrophy in the neuritis; but in the latter cases there is 
sometimes excessive development of fatty tissue in the member. Some writers have ob- 
served changes in the temperature and in the color of the skin, erythema, furunculi, patches 



ON THE TREATMENT OF NEURALGIA. 7 3 

the type of neuralgia, Here the revulsive medication, carried out in all its 
rigor, succeeds best. Sciatica is often a neuritis, and it may almost with cer- 
tainty be affirmed, when this neuralgia is obstinate, and is not due to compres- 
sion of blood-vessels, viscera, etc., that it proceeds from an inflammation of the 
nerve. I believe that this frequency of neuritis of the sciatic nerve results from 
proximity of that nerve to the surface, and from the modifications which it 
is likely to experience from external influences, and especially from atmos- 
pheric changes; there is certainly no form of rheumatic neuralgia so common. 

Apropos of these stubborn sciatic neuralgias, I must remark that they are 
often dependent on affections of the spinal cord, especially when they are 
bilateral. Essential double sciaticas are very rare, and when they occur, they 
are generally occasioned by tabes dorsalis, or, as Worms has shown, by diabetes.' 

Neuralgias of the uterus, bladder, testicle, and spermatic cord have fre- 
quently been observed. I know that it has been disputed whether these vtsce?'- 
algias ought to be considered true neuralgias, but it is of little consequence what 
we call them, they are painful affections, and prompt relief is demanded. In 
uterine neuralgia, cauterizations are of striking utility. You will in fact observe 
a certain number of females, who, apart from all organic disease of the uterus, 
suffer pains in that organ presenting all the distinctive characters of neuralgia. 
In these cases revulsive applications to the os or cervix with the Paquelin 
cautery, or the acid nitrate of mercury, give excellent, results. Do not, how- 
ever, forget that in this neuralgia of the organs contained in the pelvis, one of 
the best methods of administering anodynes is the suppository. [Here the 
morphia suppository of the United States Pharmacopoeia, with one-third grain 
extract of belladonna, will do good service.] 

Ileo-lumbar neuralgia 3 is often the cause of cruel suffering, besides being 
rebellious to the most energetic treatment. In fact, this affection is frequently 

of herpes along the tract of the nerve. Sciatica has a very irregular march. It may cease 
spontaneously, and gradually; its duration is very variable, from several days or weeks, to 
years. Relapses are frequent. The points douletireux indicated by Valleix are as follows: 
i. The lumbar point immediately above the sacrum. 2. The sacro iliac point, on a level with 
the sacro iliac articulation, in front of the posterior superior spine of the ilium. 3. Iliac, 
over the middle of the crest of the ilium. 4. The gluteal, at the top of the great sciatic 
notch. 5. Trochanteric; upper border of the great trochanter. 6. Femoral, points, superior, 
middle and inferior, on a level with the origin of the principal nerves given off from the sci- 
atic. 7. Popliteal, over the popliteal space. 8. A patellar point, over the external border of 
the patella. 9. Peroneo-tibial over the superior articulation of the tibia and fibula. 10. 
Peroneal, about the neck of the fibula, ir. Malleolar, at the posterior and inferior part of 
the external malleolus. 12. Dorsum of the foot and plantar region. 



Worms, Symmetrical Sciaticas in Diabetes, Paris, 1880. 



3 Neuralgia of the lumbar plexus is generally situated on the left side; its causes are 
various; impression of cold, contusion, alteration or compression of nerves by bony tumors, 
or other tumors in the vicinity. It may be provoked by a morbid state of the genital organs, 
testicle, uterus and its annexes, and exist at the same time with neuralgia of the neck of the 
womb. It may occupy all the branches of the plexus, or several of them, or each of the fol- 
lowing branches separately: 1. The abdominal branches which furnish the ilio scrotal nerve. 
2. The internal inguinal branch. 3. The external inguinal branch which furnishes the 



14 ON THE TREATMENT OF NEURALGIA. 

clue to profound troubles of the kidney, and particularly to renal lithiasis. You 
are aware that in these renal cases of persistent neuralgia it has been proposed to 
remove, or to open the kidney; in a word, to perform nephrectomy or nephrotomy, 
as Professor Leon Le Fort and Le Dentu have done. I pass by gastralgia, hepatal- 
gia and the greater part of the abdominal neuralgias, only referring you to what I 
have already said in regard to them while treating of diseases of the stomach, 
liver and intestines, and I come now to intercostal neuralgia. 4 This is a very 
common neuralgia, and all delicate, nervous women suffer from it more or less. 
Peter, in his remarkable lessons on pains in the side, insists that intercostal 
neuralgia is always limited to the left side; I do not quite agree with him in 
this. It is true that the far greater part of painful intercostal affections are on 
the left side. You will nevertheless now and then see hysterical patients whose 
painful sensations and whose anaesthesia are exclusively right-sided. On which- 

scrotal or labial branch. The pain, as in all other neuralgias, is permanent, dull, or con- 
tusive, or is paroxysmal. The attacks are spontaneous or provoked by walking, sudden 
movements, pressure over the nerve, etc., and remain limited to the bones, the flank, and 
the inferior part of the hypo-gastrium, or are propagated to the groin and to the testicle, 
or labia-majora, according as the scrotal or labial branch is or is not affected. Irritable tes- 
ticle, painful testicle of Sir Astley Cooper, is an ilio-scrotal neuralgia. Valleix has described 
the following foci of pain: i. A lumbar point, seated a little outside of the first lumbar 
vertebra. 2. An iliac point a little above the crest of the ilium. 3. A hypogastric point 
above the inguinal ring and just outside of the linea alba. 4. An inguinal point about the 
middle of Poupart's ligament. 5. A scrotal or labial point at the inferior part of the testicle 
or in the substance of the labia majora. 

4 Intercostal neuralgia is very common, especially in females. ^ It is unilateral or 
double, and is seated generally on the left side; several intercostal nerves being almost al- 
ways affected at the same time. Its causes are multiple; impression of cold, contusion of 
the thorax (a zona often accompanying it); neuritis, neuroma, lesion of neighboring organs 
as the lungs, pleura, vertebral column, tumors of the mediastinum, aneurisms of the aorta, 
cardiac affections, neuritis of the cardiac plexus, mammary tumors, etc. This neuralgia may 
be reflex and accompany catarrh of the digestive tube, cancer or ulcer of the stomach, or 
utero-ovarian diseases. Intercostal neuralgia may depend on disease of the spinal cord such 
as acute or chronic myelitis. It is also observed in hysteria, chlorosis, anaemia (in this case 
its seat is always on the left side), malaria, lead poisoning, syphilis, and rheumatism. 
Michel Peter in his lessons on "pain in the side" defines the pain of pneumonia as a 
pleuritic pain, and the latter as nothing but an intercostal neuropathy. The pains in the 
side observed in phthisical patients at the apex of the lungs are neurites which recognize 
for cause, inflammation of the lungs and pleura. In tuberculous neuritis it is the first, 
second and sometimes third intercostal spaces that are the seat of pain. In the neuralgia of 
chlorosis and anaemia it is the fourth, fifth and sometimes sixth intercostal spaces, and the 
pain is most severe on a level with the fourth dorsal vertebra. Intercostal neuralgia ordi- 
narily develops slowly and gradually. The pain is dull persistent, but subject to exacerba- 
tions which manifest themselves by pangs shooting through the intercostal space, or limited 
to only a part of it. These shootings of pain may come on spontaneously and provoke a 
passing dyspncea or anguish. Generally they are caused by movements of inspiration, attacks 
of coughing, pressure, by simply raising the arm, etc ; they frequently radiate toward the 
neck, shoulder, forearm, mamma. The pain in intercostal neuralgia is almost always circum- 
scribed. This enables us to distinguish it from the diffused pain of pleurisy or pleuritic 
rheumatism (pleurodynia). The fixed points described by Valleix are three in number: 1st, 
A vertebral point at the posterior part of the intercostal space a little outside of the spinous 



ON THE TREATMENT OF NEURALGIA. 75 

ever side it may occur, this neuralgia is obstinate, and resists not only morphine 
injections but also revulsive treatment. Hydrotherapy, applied in the form of 
douches to the painful region, seems to me one of the best means of combating 
this rebellious intercostal neuralgia. 

I shall finish this lecture by a brief consideration of the neuralgias of 
the fifth nerve. 

Odontalgia, 5 I need not tell you, is one of the most common of painful 
affections, and every one has at some time experienced the atrocious pain of 
toothache. This neuralgia is often determined by alveo-periostitis, or by a 
carious tooth, which affects the terminal portion of the dental nerve. There 
exists a ready means of relief for this pain in arsenious acid, which destroys the 
dental pulp, a method which Tomes, Magitot, and Combe have advised. A 
paste is recommended (to be applied on cotton to the cavity of the tooth), con- 
sisting of two parts of white arsenic, two of morphia, one of gum tragacanth, 
and one of glycerine. Among the numerous measures which have been em- 
ployed against odontalgia, Bouchaud has counselled electricity. His method is 
to place the positive pole over the diseased nerve, and the negative pole a short 
distance from it, and to pass a mild continued current. 

process ; 2d, a lateral point about the middle of the intercostal space ; 3d, an anterior point 
corresponding to the sternum (between the costal cartilages), for the upper nerves {point 
sternal), to the epigastrium, for the inferior nerves {point epigastrique). 

On making pressure over these different points the seat and nature of the pain is 
recognized. 

Intercostal neuralgia has often a long duration; it is very rebellious in some persons, 
and subject to relapses. 

5 Redier of Lille has given several formulae which apply particularly to the treatment 
of toothache. As a calmative application he advises the following: 

I£. Tinct. benzoin 3 i. 

Fluid ext. opii 

Chloroform 

Creasote aa 3 ss. 

M. — Introduce into the carious tooth on a little cotton. The whole may be covered 
by another cotton wad saturated in the following mixture: 

3$. Gum benzoin 

Alcohol aa equal parts. 

To destroy the pulp, he employs the following paste: 

1$. Acid arsenious, morphia aa 3 ss. 

Pulv. acaciae, glycerine aagr. xv. 

M. — Apply to the pulp cavity and let it remain twenty-four hours. It is generally 
necessary to renew the dressing two or three times, (a) 



(a) RedieY in Bull. Gen. de Ther., t. Oil, p. 357, 1882. Tomes, A Course of Lectures on Dental Physi- 
ology, London, 1848. Magitot, Treatise on Dental Caries, Chandler's translation; Boston, Houghton, Mifflin 
& Co., 1880. ComW, Bull. Gen. de Ther., t. XCIX, p. 485, 1880. 



JO ON THE TREATMENT OF NEURALGIA. 

A word now about facial neuralgia, 1 properly so called, These neuralgias 
affect sometimes the supra-orbital nerve, sometimes the infra-orbital branches; 
these last are the most obstinate. As I have already told you, they often yield 
readily to treatment by aconitina, or to sulphate of quinine when of an inter- 
mittent character. They sometimes defy all treatment, and have been known 
to involve the facial nerve, as well as the fifth. Without discussing the ques- 
tion of recurrent neuralgia — a subject which has of late been treated in a 
brilliant manner by Cartaz — you all know that neuralgia is often accompanied 
by painful contractions, and that to this syndrome the name has been applied 
of epileptiform neuralgia, or tic douleureux of the face. It is the most atro- 
ciously painful affection that has ever afflicted humanity, and instances have been 
known where it has driven its unhappy victim to suicide. 

It is in these cases that surgery steps in, with its nerve-stretching and 
neurectomy ; here, too, the advantages of galvanism have been lauded. If you 

facial neuralgia tic douleureux (Andre); prosopalgia (Simon); neuralgia of the face 
(Halliday); trifacial neuralgia (Valleix) comes by order of frequence after sciatica and inter- 
costal neuralgia. It may be divided, according to the seat of the pain, into ist, neuralgia of 
the optbalmic branch ; 2d, neuralgia of the superior maxillary branch ; 2d, neuralgia of the 
sensory part of the inf. max. 

It is about as frequent in men as in women ; is ordinarily unilateral. 

Causes: Cold when the individual is sweating; carious teeth ; contusions, wounds of 
the face; compression of the nerves by foreign bodies; neuromata; tumors of the petrous bone, 
aneurisms of the internal carotid ; tumor of the pons ; fungus of the dura mater. 

It may come on in the beginning or during the course of locomotor ataxia ; it may 
depend on visceral affections, fibrous tumors of the womb, gastro-intestinal troubles, malaria, 
poisoning by opium, lead, mercury ; may supervene during rheumatism, gout, syphilis, 
anaemia; may show itself after suppression of the menses, of a hemorrhoidal flux, of a habitual 
exanthem; after a severe emotion. 

It does not generally come on suddenly, but gradually. At first limited to several 
nerve branches, it only gains the others progressively. The patients experience dull, con- 
tusive, persistent pain, or paroxysmal pain which may be spontaneous or provoked by some 
movement, and even by penetrating odors. 

During the attack the patients suffer atrocious pains, often of a lancinating character, 
which call forth outcries ; they toss about on their bed and smite their head ; the muscles of 
the affected side of the face are the seat of rapid contractions, convulsive shocks, multiple 
distortions succeeding each other at very short intervals. All the muscles are not affected, 
and often the contractions are limited to the frontal portion of the occipito-frontalis to the 
zygomatici, to the inferior maxillary muscles. 

The face becomes turgescent, there is often photophobia, lachrymation, buzzings in the 
ears, then the paroxysmal shocks diminish in frequency and intensity, and all becomes 
calm ; the storm has passed, to be renewed again under the same form in a time not far 
distant. 

Every attack has not, it is true, this intensity; sometimes the lancinating pangs are of 
short duration (epiliptiform seizures). According to the branches affected, certain pheno- 
mena present themselves; photophobia, injection of the eyes, lachrymation, passing amaurosis 
in neuralgia of the opthalmic ; odontalgia, pituitary secretion in neuralgia of the 
superior maxillary ; painful deglutition and mastication, exaggeration of the salivary secre- 
tion in neuralgia of the inferior maxillary nerve. Commonly facial neuralgia occupies the 
entire trifacial nerve. 

The tender points (points douleureux), according to Valleix, are as follows: 

i. Supra orbital, over supra orbital foramen. 



ON THE TREATMENT OF NEURALGIA. i i 

employ electricity, 2 you must never exceed a certain intensity (two or three 
milliamperes, for instance); you must also, as Apostoli enjoins, make use of 
rheostats, and interpose a certain resistance to the current, to avoid thzphotofi- 
st'as which are produced with each modification of the current. It is under- 
stood that the positive pole must be placed over the painful point, and as for 
the duration of the seance, it ought to be continued till the pain disappears. 

1 must, before finishing, say something about migraine, 3 which (therapeu- 

2. The palpebral. 

3. The nasal. Internal and superior part of the nose. 

4. The ocular. 

5. The infra orbital. 

6. The malar. 

7. The superior dental. 

8. The superior labial. 

9. The palatine. 

10. The pituitary. 

11. The temporal. 

12. The temporo maxillary. 

13. The mental. 

14. The lingual. 

15. The inferior labial. 

Facial neuralgia has a variable duration, and is subject to relapses. When it lasts a 
long time, it is not rare to observe trophic troubles of the skin, which may become hyper- 
trophied, or of the hair, which may have an exaggerated growth, may fall out or turn white. 
The patients fall into a state of languor and become "used up;" others, in the worst forms 
of tic douleureux, seek in suicide a release from their sufferings. 

2 Letourneau has much employed cephalic electrization, which acts on the vaso motors, 
diminishing the cephalic congestion and even preventing the cerebral neoplasms which often 
follow repeated attacks of hyperaemia. The cerebral anaemia provoked by the constant 
currents explains the vertigo which the patient experiences under the influence of electricity, 
and the unconquerable somnolence which always follows these electrical seances, (a) 

3 Migraine is a painful affection, which has from time immemorial exercised the 
sagacity and skill of physicians. It is still almost as difficult to treat as it ever was. 

This disease, which used to be attributed to certain diatheses (arthritism, herpes, gout, 
etc.,) has been referred to a variety of causes, as disorder of the frontal sinuses (Deschamps) 
neuralgia of the 5th and 7th pairs of nerves (Chaussier and Pinel), compression of the tri- 
facial by the engorged, cavernous sinuses (Auzias Turenne). 

Some authorities consider it as a symptom of lesions of the nervous system, central 
or peripheral ; others (as Hervez and Liveing) as a discharge from the nervous system too 
charged with fluid. According to Piorry it is an ascending neuralgia, taking its departure 
from the nervous fibres of the iris. Du Bois Reymond thinks that migraine originates in the 
cilio-spinal center. 

The causes of the attack are multiple and various: indigestion, constipation, exposure 
to the open air and sunshine, fatigue of the sight or the hearing, too prolonged watching, 
absorbing intellectual labors, changes in the hour of meals, too much or too little food ; 
privation of an habitual stimulant (tea, coffee, etc.); all may provoke an attack, It is the 
same with changes of habit, and errors of hygiene, suppression of a hemorrhoidal flux, etc. 



(a) Letourneau, On Cephalic Electrization (Congres pour 1' avancement des sciences, 1878, p. 913). 



78 ON THE TREATMENT OF NEURALGIA. 

tically at least) belongs to the neuralgias. You are not ignorant of the discus- 
sions which have arisen over the pathogeny of migraine, some considering it 
simply a neuralgia of the trifacial, others as a special neurosis of the same 
nerve, or even as a neuralgia of the brain itself, a cerebralgia, as Romberg 
maintains. There are still others who assert, as does Du Bois Reymond, that 
the principal seat of migraine is the cervical portion of the great sympathetic. 
This is the view generally held in France, especially by Gubler and Jaccoud. 
It is, in fact, probable that migraine is not a simple neuralgia, but a complex 
neurosis, affecting alike the cerebrum, the trigeminal nerve, and the cervical 
portion of the sympathetic. 

Whatever its pathological nature, migraine is a very distressing affection 
and you will often be consulted in reference to it. You ought always, if possi- 
ble, to ascertain the first cause, and as far as this is concerned, this is what you 
will discover: in nine cases out of ten migraine is a diathetic affection, and for 
my part I have frequently observed it in hemorrhoidal, arthritic, and asthmatic 
subjects. Your treatment, then, should be directed to the arthritic diathesis, of 

In women it is not rare to see migraine coincide with the menstrual epoch, cease with it, re- 
appear with the next period, and cease altogether at the menopause. 

Everything in fact in the case of a person predisposed may provoke an attack ; even a 
slight blow on the head, breathing a peculiar odor, mental emotion, etc. 

Attacks vary according to individuals. Sometimes there are prodromes the evening be- 
fore ; too keen an appetite, cerebral excitation, or somnolence. Oftener the patient goes to 
bed well, but wakes up in the morning with a feeling of lassitude, torpor, and inaptitude for 
work. Others wake up feeling more active, more lively, but there are at the same time 
certain indescribable sensations known only to the migrainous, which announce the impend- 
ing paroxysm. 

Little by little the attack develops; the headache appears ; at first slight and limited to 
the forehead, the temples or the orbit ; it changes place, goes to the nucha, darts from right 
to left to return to the right or vice versa. The patient complains of a sort of cranial tension, 
of oppression over the frontal sinuses, the sensation of a leaden cap or girdle surrounding 
the head. The least movement exasperates the pain; walking, ascending a flight of stairs, 
gives a sensation as if the cranium was pounded. The patient seeks darkness, silence, rests 
apathetic, indifferent to everything, but when there are exacerbations of the pain, twinges in 
the cranium, in the orbit, he becomes agitated and wild, and only recovers calmness when 
the anguish is assuaged. The pain is habitually localized on one side (hemicrania), 
and not rarely there are irradiations to the back and front of the neck, and 
shoulders of the same side. During this time the skin is pale, or it may be slightly 
flushed, the features are drawn, the eyes encircled with a ring, the temporal artery 
beats with force. On the part of the eye there are also certain troubles, such as 
diplopia, mists before the sight, or dazzling sensations, muscce volitantes, and photophobia ; 
the eye at the same time seems smaller; the pupils slightly smaller than natural are some- 
times animated by fibrillary contractions; and the ball of the eye is tender. There 
is also in some persons perversion of the hearing (buzzing in the ears); or of the smell, 
(exaggeration or abolition). 

The appetite, abolished in some, is exaggerated in others ; certain drinks, certain 
articles of food are not supported, but there is an annoying and constant symptom, a sort of. 
seasickness — nausea followed by vomiting, which exasperates the pain, or which may even 
usher in the end of the paroxysm, or at least the end of the special malaise which accom- 
panies it (rigors, horripilation, cutaneous hyperesthesia, gaping, eructations). 

The cerebral troubles are somewhat rare. Liveing has noted cases of aphasia, and 



ON THE TREATMENT OF NEURALGIA. i\) 

which the migraine is an expression. At other times you will find the migraine 
due to causes of a different character, occasional causes to which you should 
address your therapeutic endeavors. These causes may be ranged in three 
groups; first, excess of work, and especially brain work during the night-time, 
and with the aid of too strong a light. Piorry referred all migraines to fatigue 
of the eyes; to him, migraine was only a manifestation of irisalgia. Second, 
anaemia; the megrim of chlorotics is an example, coming on whenever by any 
cause the organism is enfeebled. Third, congestive head troubles, instances of 
which we see in the hemicranias of the gouty or arthritic. 

The first class of patients are benefited by rest from mental toil, and by 
bromide of potassium; the second may require hydrotherapy and morphia; the 
third will need alkalies, intestinal derivatives, and especially aconitia. 

I have finished this long exposition of the treatment of neuralgia, an exposi- 
tion far from being complete notwithstanding its length. I believe, however, 
that I have furnished you the general principles which ought to guide you in 
your practice. 

In the combat with pain your therapeutic resources will be taxed to the 
uttermost, and you can only fulfill your professional duty by the intelligent 
endeavor always to relieve, if you cannot cure. 

Charcot has seen similar cases. Gubler and Bordier say that they have observed during the 
attack a greater facility of the circulation and respiration. 

Diarrhcea and constipation are symptoms varying according to the subjects; it is the 
same with diuresis. 

The duration of the attack is variable and often in the direct ratio of its intensity ; from 
three, four, five and six hours to twenty-four, thirty-six, forty-eight, and even more. The 
pain in some persons is gradually alleviated during the day, especially during conversation ; 
in others, after a short lull it reappears, and only is calmed when the patient succeeds in 
going to sleep, after long searching for a place on his pillow which is not too hard for his 
head. He wakes up restored, or with a weight in his head which little by little goes away, 
or is only the prelude to another attack. 

The attacks, whose intensity is extremely variable, sometimes present themselves in a 
regular manner, at fixed periods, which gradually become longer and longer with age, and 
finally the disease disappears altogether, or is replaced by gout, hemorrhoids, asthma, or 
some cutaneous or other affection. 

The baldness seen in some migrainous patients is rather due to pityriasis capitis than to 
the migraine. 

After the attack the health is often excellent ; the patient recovers his natural tone and 
spirits, and experiences a Hen etre which is wanting when by any means the paroxysm is 
aborted. 

Migraine is most common in the female ; it attacks all classes of society, {a) 



{a) Tissot, Des nerfs et de leurs maladies, t. XI, Paris, 1873. Bouillaud, Nosographie medicale. Pelle- 
tan, Coup d'oeil sur la migraine et sur ses divers traitements. Du Bois Reymond, Archiv. fiir Anal., 4e 
livraison, i860, p. 461. Gubler et A. Bordier, Dictionnaire encyclopedique des sciences medicaies, art. Mi- 
graine. Piorry, M^moire sur la migraine; Trait, med. pratique, t. VIII, p. 75. 



ON THE TREATMENT OF HYSTERIA. 

Summary : Difficulty of the Subject — Vague Delimitation of Hysteria — Comprehends a Great 
Number of the Diseases of the Nervous System — Impossibility of Assuring a Therapeutic 
Result in Certain Cases of Hysteria — General Treatment of Hysteria — Hygienic Treat- 
ment — Education, Its Role as a Prophylactic — Influence of the Uterus in Hysteria — 
Influence of Continence — Of Marriage — Influence of the Husband — Kind of Life — In- 
fluence of Disappointments — Excitement — Alimentation — Medical Treatment — Anti- 
spasmodics — Valerian — Castor Assafoetida — Bromides — Baths — Hydrotherapy — Means 
of Application — Mineral Waters — Electricity — Influence of Static Electricity — Galvanism 
Metalloscopy and Metallotherapy — History — Burquism — ^Esthesiogenous Substances — 
Results of Metallotherapy — Its Modes of Application — External and Internal Metallo- 
therapy — Treatment of the Attack — Cold Water — Compression of the Ovary — Mechanical 
Compression — Galvanism — Medicinal Inhalations — Nitrite of Amyl — Treatment of 
Certain Symptoms — Paralysis — Contractures — Anaesthesia — Amaurosis — Gastric Hys- 
teria — Anorexia — Vomiting — Anuria — Electricity — Ether Spray — " Gavage " — Con- 
clusions. 

Gentlemen: — In taking up as my subject to-day the treatment of hysteria, I 
do not conceal the difficulties of my task. Hysteria embraces a great number 
of affections of the nervous system, from the so-called " vapors " of hypochon- 
driacal females, tothathystero-epilepsy 1 so recently described by Charcot as the 

1 As the observations of Briquet show, hysteria may manifest itself in infancy, be 
hereditary or acquired, or appear at a more advanced age under diverse influences. It 
comprehends two forms: the convulsive form {petite hysterie, and grande hystc'rie) and the non- 
convulsive form. 

Convulsive hysteria comes on in paroxysms or fits preceded for a short time by pro- 
dromes, consisting in psychical troubles, troubles of the organic functions, troubles of 
motility and troubles of the sensibility. 

The psychical troubles sometimes appear several days before the attack. They consist 
in a change in the disposition and moral deportment. The patient is no longer interested 
in her daily duties, neglects her toilet, becomes gloomy, morose, or even gay and silly, is 
anxious about trifles, has attacks of jealousy, hatred, raises disturbances and quarrels with 
everybody. 

Frequently there are hallucinations in the night time and even by day. These 
show themselves on the side that is anaesthetic (Charcot), and consist in visions of black 
cats, rats, spiders, vipers, etc., and these animals flit from left to right and from right to left 
according as the anaesthesia is on the left or right side. It is the same for the hallucinations 
of hearing, which are less common than those of vision. There are hissing noises in the 
ears, roarings, ringing of bells, etc., which are heard in the anaesthetic side. Sometimes 
the hallucination of sight is the prelude to the attack. The patient has the eyes fixed, widely 
opened, staring at vacancy, then the attack comes on. The troubles of the organic func- 
tions consist in digestive, secretory, respiratory, circulatory disturbances, want of appetite, 
vomiting or nausea, ptyalism, laryngeal troubles, spasmodic cough, palpitations, hiccough, 
paroxymal bursts of laughter, spasm of the throat, hysterical suffocation. Among the 
troubles of motility, there is noted an amyosthesia more marked than is habitual, painful 
cramps, trembling or convulsive startings of a partial or general character, affecting especi- 
ally the anaesthetic side. These epileptoid commotions sometimes precede the attack by 
only a few minutes. Besides the convulsions, contractures are also observed beginning 
suddenly and occupying one member first before becoming general, and fixing the patient in 

80 



ON THE TREATMENT OF HYSTERIA. 81 

great hysteria. If the domain of this neurosis is immense, its limits are far from 
being precise, and he would be a bold man who would in all cases venture by a 
hard and fast line to separate nervousness, hypochondriasis, epilepsy, and even 
lunacy, from hysteria. So, as Lasegue has very judiciously said, we are not 
able to-day, and perhaps never shall be able, to give an exact definition of 

a particular attitude. The troubles of sensibility consist in a total or partial anaesthesia 
(hemi anaesthesia), and becoming more marked if it existed before. Certain patients mani- 
fest, on the contrary, hyper-aesthesia ; in others the sensorial sensibility is affected 
at the same time (amblyopia, deafness, etc). Such are the remote prodromes of the attack. 
Those which are the nearest the paroxysm are certain painful phenomena, constituting the 
aura hysterica. The aura may have different seats, taking its departure from the hypogas- 
trium or the abdomen, from the ovary or other hysterogenous points or zones, varying ac- 
cording to the patient. 

These zones exist upon all points of the body; zones above and below the mam- 
mary region, zones costal, iliac and ovarian, superior and inferior dorsal, etc. 
The point the most frequently observed is the ovarian. Pressure over any one of these 
points may provoke the attack when the convulsions are absent, but may also arrest it 
when the convulsions do exist, on condition always that the pressure be strong enough. 

The aura is spontaneous or provoked ; if, for example, you make pressure over the 
ovarian point, the patient complains of a pain, sometimes very keen, which radiates toward 
the epigastrium, with painful constriction, nausea and sometimes vomiting (first link in the 
aura); then, if the pressure be continued, palpitations of the heart, the globus hystericus (second 
link in the aura); the sensation of a ball which, starting from the abdomen mounts upward to 
the thorax and reaches the larynx. Then follow cephalic troubles ; hissing in the ears, sen- 
sations as though the temporal region were pounded by a hammer, and obscuration of the- 
sight, sensations which are right or left according to the side of the ovary which is com- 
pressed. The patients become unconscious (third link in the aura), and the convulsive 
paroxysm bursts forth ; the patient falls down, but does not utter a peculiar cry like an ; 
epileptic patient ; the face is congested, she puts her hands to her neck as if to tear away a 
tight cord that is choking her, lets escape a few sighs, then hiccough and convulsions 
appear. In some cases, nevertheless, the attack is sudden, and the loss of consciousness 
instantaneous. 

Charcot recognizes four periods in the attack : an epileptoid period, a period of clonfam 
(contortions), a period of passional attitudes, and a period of delirium. The first period 
resembles an attack of epilepsy, with tonic and clonic convulsions, and resolution. The 
tonic phase may be subdivided into "tonic with movements that have a wide range, or tonic 
convulsions," and "tonic with tetanic immobility, ortetanism." 

The movements in the first phase resemble much those observed in partial epilepsy 
called by Richer tonic partial epilepsy ; they are slow, extensive, general, but predominating 
on one side; they are movements of circumduction. With the superior members the inferior 
members are agitated as well, and the trunk does not remain passive, it turns from side to side, 
flexes or extends, contortions carry the pelvis in all positions, the head goes from right to- 
left, or makes movements of salutation more or less violent. 

To this period succeeds the tonic phase, with immobility; the muscles are tetanized, the 
patient remains fixed, the head is bent backwards, the neck is prominent, swollen, the face 
cyanosed, and bloated. The upper limbs are stiff in different positions, the hands tightly 
shut, the thumb against the palm of the hand covered by the other fingers, the legs extended,, 
strongly pressed the one against the other. The entire body is fixed in different strange 
attitudes, the arc of a circle, a ball, etc. The patient has completely lost consciousness and 
there is spasm of the respiration. 

But soon (clonic phase) supervene brief and rapid oscillations in the tetanized members; 

they succeed each other rapidly, become general, the tetany ceases little by little, respiration, 
§6 



82 ON THE TREATMENT OF HYSTERIA. 

hysteria ; we can only affirm that, by its strange manifestations, hysteria has 
erased the word impossible from pathology. 

But, before entering into the details of the question, I owe you a declara- 
of principle ; it is that, from the point of view of treatment, hysteria, by its very 
nature, defies all positive and scientific therapeutic rules. This results from 

is resumed; to a whistling inspiration succeeds a jerking expiration, then comes muscular 
resolution, sometimes incomplete and interrupted by sudden starts which give the patients 
strange attitudes. The breathing becomes regular, but remains loud and stertorous. 

After the epileptoid period, whose duration is variable, and of which any one of the 
phases may be modified, prolonged to the detriment of the others, or be wanting altogether, 
appears the period of contortions and of grand movements. In the period of " clonism " 
the patients assume divers attitudes, the most strange and bizarre; the most common, how- 
ever, is that of the bow, [arc en cercle], the body being arched forward or backward, or 
laterally, (emprosthotonos, opisthotonos and pleurosthotonos). 

In the phase of "grand movements" the body executes very extended movements. 
Many patients, however, are seized with a sort of fury, strike, tear everything within their 
reach. Then is ushered in the period of "passional attitudes or fictile postures." The 
patient is a prey to hallucinations, and her countenance, her fictile postures betray the thoughts 
which by turn agitate her. During this period she is quite insensible to all external ex- 
citations. 

In the fourth period, (period of delirium) which succeeds the third, with which it is 
often confounded, consciousness returns in part, the patient remains a victim to delirium 
attended with hallucinations and sometimes with troubles of movement. The delirium is 
often a delirium of memory and the patient recounts a scene in her past life ; in her 
hallucination she hears voices, the sounds of bells, sees animals, etc. 

The troubles of movement consist in a general or partial contracture and persist some- 
times after the attack for variable periods. The attack frequently terminates by an abundant 
emission of tears, of urine or vaginal mucus. 

Such is hystero-epilepsy in its ordinary manifestation. Generally the attacks are not 
single, but several appear in rapid succession, running into each other, without any return 
of consciousness; they may, however, be separated by lucid intervals. The attacks maybe 
as many as a hundred a day, each with varying duration and intensity. 

"Petite hysterie" (the minor hysteria) is an attenuation of the grand. It is almost 
always ushered in by prodromes: palpitations, yawning, lassitude, malaise, motiveless bursts 
of crying or laughing, painful sensations in the region of the ovary, a ball rising in the chest 
and coming up to the throat (globus hystericus), whistling noises in the ears, then the patient 
falls with loud shrieks, her head is thrown backward and is stiff, the face, pale at first, be- 
comes congested; the eyes roll in their sockets, the pupil dilated, sometimes contracted, 
hides itself under the upper lid. The mouth is wide open, the tongue moves from side to 
side or is thrust forward. Often there is gnashing of teeth; then in the midst of sobs, hic- 
cough and convulsions set in. 

In the great hysteria, according to Charcot and Fere, from the commencement the 
pupil is contracted during the tetanic period, to be in turn dilated during the great move- 
ments; during the phase of passional attitudes and delirium, it is alternately contracted and 
dilated. Compression of the ovary modifies the dimensions of the pupil, as it modifies the 
march of the attacks, (a) 



O) Landouzy, Traits Complet de 1. hysterie, Paris, 1846. Briquet, Traitd clinique et therapeutique de 
1. hysterie, Paris, 1859. Bernutz, Lecons cliniquessur 1. hysterie, (Gaz. des Hop, p. 83, 1874, et art, Hysterie du 
Diet Encycloped ) Richer, Etudes Cliniques sur 1. Hystero-epilepsie, 1 vol. de 764 pages. Paris 1881. 
Charcot, Description da la grande attaque hyste>ique. (Progres Med., 1879, p. 17.) Ch. F<*re. Notes pour 
servir a 1. histoire de 1. hystero-epilepsie. (Arch, de neurologic Paris, 1882, p. 360.) Huchard Tiaite des 
^evroses. Paris, 1883, p. 919. 



ON THE TREATMENT OF HVSTERIA. 83 

two causes : first, the preponderant part which the imagination plays in this 
disharmony and disordered equilibrium of the functions of the nervous system, 
and which determines, as a consequence, that oftentimes where the physician, 
well-informed, conscientious, patient, devoted, fails, the most brazen charlatan 
will easily succeed. Hysteria is, in fact, the harvest-field of quacks, the domain 
of miracles and surprises. A second factor of importance, as having a bearing 
on the therapeutics of hysteria, is the disposition which the hysterical female has 
to deceive her attendants, a disposition which Dally has characterized by the 
name delire malicieux (malicious delirium). 1 

This mental condition of hysterical patients, to which Huchard attaches so 
great an importance, will prompt intelligent females to endure extreme tortures 
in order to maintain a morbid state which their will alone has engendered. It 
results from this singular perversity, that every exhibition of drugs and every 
therapeutic application which has for its end the treatment of hysteria, may be 
attended with disappointment ; and that one can never affirm that a medica- 
ment which has given good results in one case of hysteria will give the same 
results in another case. In a word, in this neurosis everything may fail, and 
everything may succeed. 

With these reservations (which it belonged to me to make), I come to the 

1 By the side of the sensory or motor troubles, and the convulsive phenomena observed 
in hysteria, it is interesting to take note of the changes which in this neurosis manifest them- 
selves in the character, the moral disposition and intelligence of hysterical females. 

One of the dominant traits of character in these patients is their mobility. They are 
seen to pass from one movement to another, from the most lively joy to the most complete 
sorrow. They laugh, they weep, they sigh readily and very often without any apparent 
motive. 

They converse with volubility and even vivacity, or remain as mute as the dead ; gay 
today, they are to-morrow gloomy, taciturn, and reserved ; amicable and sweet naturally, 
they suddenly become cross and peevish ; they detest what they adored only an instant 
before. 

They search even for everything which can injure the object of their hate, invent 
stories and misrepresent facts, which they present in a bad light. This is the history of 
many households which at first sight seem to be happy and harmonious, but become a hell 
under the dominion of a hysterical person. 

Hysterical females, in a word, manifest a want of mental equilibrium which causes 
that insensible to a real misfortune, before a trifling disaster they exhibit the most 
extravagant sorrow ; they are, moreover, unable to resist the impression of the present 
moment. 

When they are, several of them, brought into company together, as in a hospital, you 
will see them on the alert for mischief, making confidants of one another, fomenting little 
quarrels, and denouncing each other ; their fickleness, their want of discipline, their per- 
petual fault-findings keep the whole hospital in a broil. They seek to attract attention, and 
often lie without any motive; they simulate sicknesses from which they are entirely exempt ; 
they even go so far as to threaten to play the comedy of suicide, announcing that such a day 
and such an hour they will make way with themselves, which they take good care not to do. 
In a word, they strive to make themselves objects of interest, and it is their vanity and their 
delight to make people believe extraordinary things about them. One says that she never 
eats anything, and refuses all victuals of every kind and in some hiding place in the night 
time with wonderful cunning she devours the food which she had there concealed ; another 
one, before her physician, vomits urine which she had just before drank in her hiding place. 



84 ON THE TREATMENT OF HYSTERIA. 

treatment of hysteria, which comprehends three parts — the general treatment; 
treatment of the attacks; and, finally, the treatment of certain hysterical 
symptoms. 

The general treatment of hysteria is subdivided into hygienic and medical 
treatment. We will commence with the hygienic treatment. Here the first 
place belongs to education, as being of prime prophylactic importance. We 
can, in fact, in the majority of cases, prevent the development of this neurosis, 
for it is hereditary, and a hysterical mother has a great chance of seeing her 
children neuropathic or hysterical. 

I believe that the education of children, when they have attained the age 
of eight or ten years, ought not to be left with the mother. I would remove 
the young child, and particularly the young girl, from a tutelage too indulgent, 
too tender, and too ill-regulated; the child should never be allowed to witness 
any hysterical manifestations on the part of the parent, for imitation plays a con- 
siderable role in hysteria. 

It is a good plan to place the girl in a boarding-school, situated, if possible, 
far from the city. I say boarding-school, for isolation is a bad thing in hysteria 
and education with other girls and boys, notwithstanding some serious incon- 
veniences, has real advantages in the case of neuropathic children. Young 
girls with predisposition to hysteria, should not be permitted to read exciting 
novels, fairy tales, etc., which heat the imagination. Even the culture of piano 
music, and especially organ-playing, has disadvantages which make it desirable, 
when possible, to interdict these accomplishments. I have seen hysterical 
patients who have found in the practice of the organ an aggravation of their 
nervous symptoms, and this as well as from the excitement to the nervous cen- 
tres occasioned by working the pedals with the lower extremities, as by the 
effect of the music in stimulating their emotional natures. 

On the other hand, neuropathic girls should be allowed physical exercise 
in the open air, horseback riding, gymnastics, even swimming. In fact, 
their discipline should be fortifying, virile, and severe. I say severs, but it will 

Having a passion for the marvellous and extraordinary, they often put themselves in the 
attitude of victims and heroines, and invent stories in which they play an important part. 
They accuse themselves of imaginary crimes, or simulate wounds; and with invincible per- 
tinacity, they even accuse innocent persons of crimes which exist only in their imagination, 
and these charges they maintain to the end. The annals of justice are full of such 
monstrous facts. 

Arrived at this point, a prey to fixed ideas, which constitute, according to Esquirol, a 
catalepsy of the intelligence, these unhappy persons have no longer entire responsibility for 
their actions. They act under an impulse which they cannot resist, and all reasoning, all 
prayers and entreaties are powerless to deter them from their mad purposes. They are real 
victims of mental alienation; one will maintain that she lacks a viscus, the stomach for example, 
and will no longer eat, will let herself die of starvation; another will assert that she is turned 
into glass, and will not dare to move, etc., etc. (a) 



(a) Bodeau, Etude sur la folie hysterique, these de Bordeaux, 1881. Voisin, De la folie hysterique, 1880, 
p. 122. Duponchel, De la folie hysterique, these de Paris, 1857. Huchard, Character, Manners and Mental 
state of Hysterics. (Arch, de Neurologie, 1882.) Dally, De l'etat malicieux des hysteriques, (Bull, et Mem. 
de la Soc. de therapeutique, 1881.) 



ON THE TREATMENT OF HYSTERIA. 85 

not do to go to the other extreme, and, while interdicting romances and dancing, 
develop unduly the religious emotions, for it is quite possible to cultivate 
in them a state of religious mysticism and ecstacy, which is nothing less 
than the very disease against whose protean manifestations we are contending.' 

It is generally at the epoch of puberty in young girls, and at the time of 
the appearance of the menses, that the first manifestations of hysteria occur. 
Although the old doctrine that would place in the uterus itself the exclusive 
point of departure of hysteria, and which has given it its name, is to-day 
abandoned — since we do now and then observe hysterical men, and even in 
the female this neurosis may develop without any uterine trouble at all — 
it is none the less true that the uterus plays a preponderating part in this 
neurosis. 

Michelet, in one of his works, has given the following definition: "Woman 
is a womb, served by organs." This somewhat spiteful definition finds justifi- 
cation in the case of the hysterical female, to whom it is especially applicable, 
and it may be established as an immutable law, that in hysteria it is during the 
menstrual period that the nervous symptoms are most accentuated; this period, 
then, claims your most watchful attention, and your treatment ought always to 
follow these menstrual epochs. This question of the rdle of the uterus leads me 
to speak of another point of hygienic treatment in hysteria to which great 
importance has been attached. I refer to continence and to marriage, and I 
ask you patiently to follow me in what I have now to say touching this debat- 
able question. 

Plato compared the womb to an animal which has but one end to fulfill, 
that of conceiving, and which becomes furious when its functions are not 
accomplished. 5 From this is derived the doctrine that continence is one cause 

1 Herbert Spencer, in his treatise on education (Appleton ed., p. 212), has these golden 
words, which, if they summarize the highest duty of the educator, also convey a valuable les- 
son to the intelligent physician who would be to his constituency more than an administrator 
of drugs. A "self-governing being" is not merely one who is governed by others — it is a 
being whose lower propensities are subordinated to the higher; in hysteria this subordina- 
tion is lacking. 

" Bear constantly in mind the truth that the aim of your discipline should be to produce 
a self-governing being; not a being to be governed by others." — Trans. 

2 The ancients, believing that hysteria was only the result of uterine fury, considered as 
demonstrated the influence of continence on this neurosis. Hippocrates and Galen admitted 
this opinion without dispute; they maintained that the seminal matter ought, like other excre- 
mentitious matter, to have a ready vent, and when this seminal matter, which was by nature 
cold and aqueous, was accumulated in the economy, it produced syncope and other hysterical 
accidents. 

Too long the words of the masters have held sway over the minds of men, and the doc- 
trines of Hippocrates and Galen were accepted without dissension. It was not till the dis- 
covery was made that the ovaries secrete ovules, and not seminal liquor, that doubts began 
to be entertained concerning the Galenic doctrine, and it was Dubois, of Amiens, who, in 
our time, was one of the first to protest against this notion of the influence of hysteria, a 
notion which was held by Georget, Brachet, Sandras, Giraud, Lelut, Gendrin, and 
especially by Landouzy. 

It is Briquet who has advanced the most serious argument to show that continence plays 



86 ON THE TREATMENT OF HYSTERIA. 

of hysteria, and that sexual relations are essential to a cure. This doctrine is 
so much in vogue, here in France, that one needs only utter the word hysteria 
in a family to suggest the idea of excess of continence to those attending on the 
patient, and in some circumstances this would be taken as an insult. Hence, I 
advise you to be chary in the use of the word in your private practice, especially 
in the presence of the family; say that the patient is neuropathic, that she is 
affected with nervousness, but avoid the word hysteria. 

This popular opinion is based — bear in mind — on the declaration of med- 
ical men, and till recently the majority of physicians who have written on hys- 
teria, and their number is considerable, have maintained the influence of 
continence on the development of this neurosis. Briquet was the first to take a 
stand against this way of thinking, and the arguments which he has adduced 
have, in my judgment, a high cogency. He has shown that when you take 
under consideration groups of females who from the point of view of sexual 
relations lead quite opposite lives, nuns, on the one part, among whom conti- 
nence is the rule, and prostitutes on the other, among whom continence is 
unknown — he has shown, I repeat, that hysteria is much more common with the 
second class than with the first. Moreover, do we not see in our hospital ser- 
vices that the greater part of our hysterical patients are women to whom conti- 
nence is the rare exception, and who have a more than sufficient satisfaction of 
their sexual wants ? I quite agree with Briquet, and believe that if continence 
may have a certain influence on hysteria, an influence by no means scientifically 
demonstrated, genital excitations are quite as detrimental. 2 

only a secondary role in hysteria; he has based his doctrine on 430 cases which he has wit- 
nessed, and these are his conclusions: 

1. That widows are no more liable to hysteria than other women; this neurosis 
results much oftener from moral and emotional than from other causes. 

2. That, contrary to the assertions of authorities, hysteria is very infrequent above 30 
years, and very common below that age. 

3. That hysteria appears in a fifth part of predisposed patients before the age of puberty, 
and that then it can have no relation with continence. 

4. That this disease is less common in married females than in the unmarried, but 
only in the proportion of 7 to 9. 

5 . That it is not now frequent in persons who live continent lives, and that it is on the 
contrary somewhat more frequent in those that are wanting in chastity. 

6. That the satisfaction of the sexual wants does not in any way give exemption from 
hysteria. 

7. That it is untrue that hysterical attacks often terminate by an evacuation of a liquid 
coming from the genital organs. 

8. That it is untrue that from the time that the genital organs have arrived at their 
complete development, it is necessary that their functions shall be exercised under penalty 
of hysteria. 

9. That it is possible that in certain circumstances not well defined, the genital wants, 
naturally or artificially aroused, and lacking a sufficient satisfaction, may be a cause of pain- 
ful excitation of the encephalon, from which may spring a disposition to hysteria; but, thus 
far, this predisposition must be admitted as a result of deduction, rather than as a direct con- 
sequence of observation. (a) 

2 Briquet, Traite de l'Hysterie, Paris, 1859. 



(a) Briquet. Traite" de l'hysterie, p. 126. 



ON THE TREATMENT OF HYSTERIA. 87 

Families will often ask you whether young hysterical girls ought to marry; 
it is best to be non-committal in this matter, and not affirm, as has often been 
done, that marriage may cure the hysteria. 1 To counsel marriage in such a 
case is a responsibility which the physician ought not to assume, for it is not 
proved that marriage ameliorates the condition of a hysterical person, and in 
order to obtain a problematical benefit, he may doom a husband to a life of 
chagrin and unhappiness. 

It would be a curious chapter which should relate the history of the part 
which husbands have to play in this deplorable neurosis. The husband of a 
hysterica] woman often finds himself in a sorry plight. However amiable and 
attractive, however persuasive and commanding, he can neither please nor 
control a woman of disordered brain, before whose capricious whims he is 
powerless; whose actions, however seemingly reprehensible, are performed al- 
most without volition and without consciousness. In other cases the husband 
undoubtedly favors the development of hysteria in his wife by the incessant 
concern with which he treats her manifestations. By the attentions which he 
lavishes on her, by the anxious exaggerated affection which he displays, he 
fosters and encourages the ataxic phenomena. The man is fortunate who, 
constantly and sympathetically watching the hysterical explosions of his wife, 
does not, by imitation, become hysterical himself. The spectacle has more 
than once been witnessed of a neuropathic couple (generally without children) 
bewailing and intensifying their mutual ailments. Here separation is most 
salutary to both parties. 

Fortunately, the marriage of a hysterical person is not always so gloomy in 
its results ; where especially the husband, by his coolness and firmness, his 
good sense and moral influence, gives to the wife a sage and dominant direc- 
tion, which mitigates and moderates the nervous phenomena. 2 While, then, it 
may be said that marriage is a good thing for hysterical women, when it brings 

1 The Hippoeratic notions concerning continence had one practical consequence, viz: the 
tenet that marriage was curative in hysteria and this doctrine may be summed up in these 
words; Fcemina hysterica eget viri, ergo vir praebeudus est. Valescus of Tarentum favors this 
notion. Forestus affirms that hysterical patients must be made to marry, if they would escape 
the exciting consequences of an accumulation of sperm. Sennert, Baillou, Duret and Riviere 
adopted this view of Hippocrates and Galen, and carried it farther than they. Bouvard 
Antoine, in his thesis defended in 1612, affirms that it is necessary, in order that marriage 
may succeed, that it take place, cuju viro succulento. Similar theses, moreover, characteristic 
of the times, were maintained in 1560 and 1564, by Tauret and Daguet, and had for title, An 
Venus hystericisl Landouzy, in our epoch, has affirmed that marriage being the physical and 
moral union of beings according to the purpose of nature, is one of the most powerful means 
of prevention and cure of hysteria. Briquet has risen against this doctrine, and has shown 
that marriage has little effect on hysteria; he has cited instances of hysterical women having 
had 22 accouchements and abortions. He has shown that of 98 cases, in 50 marriage was 
injurious, in 31 without any influence, and in 17 it was attended with amelioration, {a) 

2 Bernutz thinks that marriage may in certain cases be useful when hysteria has not 
gone too far ; in support of his opinion he observes: first, that an early marriage prevents a 
great number of young girls belonging to the lower classes of society from contracting 



a Briquet, Treatise on Hysteria, page 46] 



338 ON THE TREATMENT OF HYSTERIA. 

with it happiness and tranquillity, it is nevertheless true that oftentimes those 
most favored by fortune and surrounding conditions, whose life, calm and 
peaceful, ought to be without a cloud, suffer from groundless fears and imagin- 
ary ills, and are always unhappy beings, and all in consequence of an ill- 
balanced nervous organization. 

There is no kind of life which is exempt from hysteria, and we find this 
•-neurosis among the poor and among the rich, those that labor and those that 
Jiire ; we see constantly examples in our private practice, and in our hospital 
service. The country also furnishes its contingent of hysterical patients. It 
has been maintained that country life preserves from hysteria. This is a mis- 
take, and we observe instances the most curious and obstinate of this neurosis 
is our rural villages. Apart from heredity, disappointed hopes are a most 
prolific cause of hysteria, and whatever the station or occupation in life, de- 
pressing cares and disappointments will come. 

As occasional or aggravating causes of hysteria, we may refer to two kinds 
of life diametrically opposite: on the one hand, a too fashionable life, with all 
Its pleasures and all its fatigues ; on the other hand, a too solitary life, with all 
the ennui which accompanies it. In the one case the hysteria is brought on by 
nervous excitement, in the other by a morbid brooding over neuropathic 
symptoms which are thereby perpetuated and aggravated. It is important, 
then, that you should find diversions for your hysterical patients, but such 
diversions should not exceed certain limits. 

As for diet, it should be of a nourishing and unstimulating character. I 
advise you especially to forbid the use of tea and certain alcoholic liquors. I 
believe that the abuse of tea is an occasional cause of hysteria, especially where 
one is not accustomed to it, and I have seen nervous women improve with sup- 
pression of this beverage. 

Among the wines, you ought especially to forbid heady and sparkling white 
wines, as champagne, all the strong alcohols, and particularly absinthe. Lance - 
reaux has, m fact, shown that in alcoholic patients, and especially absinthe- 
takers, there exist sensory troubles akin to those of hysteria, and it is 
probable that the greater part of men who are afflicted with hysteriform 
:neuropathic disorders are men who have been addicted to alcoholic stimulants 
and to absinthe. 

I come now to the medicinal treatment of hysteria. This treatment will 
comprise three parts: the pharmaceutical treatment, the treatment by balneo- 
therapy, and the treatment by electricity and metallotherapy. 

The pharmaceutical treatment formerly consisted in the administration of 
that class of medicaments described under the name of antispasmodics, such as 

illicit liaisons ; second, that celibacy, which is an abnormal state, is, by the preoccupations 
of every kind which it engenders in young girls of the opulent and middle classes, as fruitful 
a cause of hysteria as misconduct ; third, that often marriage is the very way to change the 
conditions of life for a great many young girls whose hysteria is fostered by the bad influence 
of the family which surrounds them, (a) 



{a) Bernutz art. Hysteria in Nouv Diet de med. et de chir. t. xviii. 



ON THE TREATMENT OF HYSTERIA. 89 

(more especially) valerian, musk, castor, galbanum, and assafcetida. 1 The 
greater part of these medicaments are to-day almost forgotten, and this for 
several reasons: first, because their antispasmodic effects are far from being 

1 Assafoetida is the concrete juice of the root of Narthex assafcetida, an umbelliferous 
plant which flourishes in Persia, and the adjacent countries. It is obtained from incisions 
made in the upper part of the root. In commerce it is met with in the form of tears or 
irregular reddish-brown masses. Its chief constituents are resin and gum, from 50 to 75 
per cent, of the former, and about 20 per cent, of the latter, besides nearly four per cent, of 
volatile oil. 

The officinal preparations are the emplastrum, the mistura, the tincture, the pilulse (pil. 
assafcetidae and pil. assafcetidae et aloes). The Pil. Galbani Co. also contains assafcetida. 

In Persia, assafcetida is used as a condiment, either mixed with the food, or rubbed 
upon the vessel in which the food is contained. It is regarded as useful in correcting the 
flatulence to which the Orientals, as vegetable eaters, are subject. The Germans call 
this drug stercus diaboli, while in the East it is known by a title that signifies God's meat. 

This drug has no very marked medicinal properties; it gives to all the excretions the 
odor of assafcetida. It has been of use principally in the treatment of functional nervous 
affections. 

Besides the officinal preparation above mentioned, the author gives several popular 
preparations in use on the Continent from which we select the following: 

ANTI-HYSTERIC DROPS (GERMAN PH.). 

I£. Tinct . assafcetida, 15 | ( § ss). 

Tinct. castor 12 | (3 iij). 

Tinct. opii 4 j (3 j). 

M. Sig. Twenty or thirty drops in potion or in lavement two or three times a day. 

ANTI- HYSTERICAL LAVEMENT. 

1$. Ext. valerian, 10 | (3 ijss). 

Camphor, | 75 (gr.xii). 

Yolk of one egg. 

Laudanum, gtt. xx. 

Water, 300 | ( 1 x). 



M. 



ANTI-HYSTERIC PILLS (BAILLY). 



1$. Powder of castor, "] 

" " amber resin, I .... , , .. 

"assafcetida, ( aa " 4 > <■ 3 »' 

" " valerian, J 

" " camphor, | 60 (gr.x). 

Syrup papaver, q. s. 
F. S. A. Massa, div. in pil. q. s. 
Each pill should weigh about 30 centigrams, or five grains. Give 7 or 8 a day. 

ANTI-HYSTERIC PILLS (DR. BREYNE). 

1$. Camphor, assafcetida, aa 12 | (3 iij). 

Ext. Bellad 4 | ( 3 j). 

Ext. opii 1 I (gr. xv). 

Syr. acaciae. q. s. 
M. F. S. A., pil. No. 120. Sig. Give one pill the first day, and increase by one pill a 
day till six are taken in the 24 hours, (a) 



(a) Dujardin Beaumetz. Diet, de Ther. t. I. Ar.. Assafcetida. Stille. Therapeutics and Materia 
Medica, Art. Assafcetida. 



90 ON THE TREATMENT OF HYSTERIA. 

demonstrated, and, in the next place, because they have been superseded by a 
more active medication, that of the bromides. I shall not, then, dwell on all the 
numerous formulae of potions, syrups, pills, ptisans, suppositories and lavements 
of supposed anti-hysterical virtues, 1 for which I refer you to your ancient formu- 
laries; but before passing to the bromide treatment, I desire to say a few words 
about valerian, which still enjoys a certain repute in the treatment of hysteria. 

Valerian, the officinal portion of which is the root, is administered in 
infusion, in tincture (the ammoniated tincture is perhaps the best preparation), 
in the form of valerianates, and especially of valerianate of ammonia. For my 
part I have little faith in the therapeutic action of these valerianates, and finish 
what I have to say of this medicament by adding that the pills of Meglin, so 
much prescribed for nervous disorders, contain a notable quantity of extract of 
valerian. 1 

Who says hysteria, says bromide, and at the present day there is not a 
hysterical person but has taken bromide. The bromide of potassium is the 
most often employed, but you may also use the bromides of sodium and ammo- 
nium in combination with it, constituting solutions of the mixed bromides, of 
whose effects Charcot has spoken so highly. Here is the formula which I 
habitually use: fy. — Bromide of potassium, bromide of sodium, bromide of 
ammonium, aa x; water ccl. — M. Signa. — From a dessertspoonful to a table- 
spoonful night and morning. 

I do not intend here to enter into the details as to the physiological action 
of these bromides, of which I shall have more to say when I come to the 
treatment of epilepsy. What I wish now to impress upon you is that these 
medicaments are among the most powerful depressants of the cerebro-spinal 
axis, and that it is owing to them that we can control the exaggerated manifes- 
tations of the nervous system. If we add that the bromides allay genital 
excitation, you comprehend all the advantages which may be derived from this 
precious remedy in the treatment of hysteria; at the same time I am far from 
affirming that the bromide medication is to be applied indiscriminately to all 
cases of hysteria, and it is because abuse has been made of this medicament 
that we see to-day certain physicians maintaining that it is rather detrimental 
than useful in the treatment of hysteria. This is by no means the case; only 
here, as for other medicaments, it is necessary to know the indications and 
contra-indications for this bromide treatment. Moreover, we must not fail to 
keep in mind that whatever may be the relationship between hystero-epilepsy 
and epilepsy (and some pathologists affirm a very close relationship), there 
exists, from a therapeutical point of view, a great distinction between these 
two affections. In fact, while epilepsy is tributary to the bromide medication, 

1 This is the formula of Meglin's pills called compound pills of hyoscyamus and vale- 
rian. 

1$. Alcoholic extract of hyoscyamus, 
Alcoholic extract of valerian, 
Oxide of zinc, aa io grm. (or 3 ijss.) 

M. S. Divide in pil. No. cc. 



ON THE TREATMENT OF HYSTERIA. 91 

this same treatment has never effected a cure of the attacks provoked by 
hystero-epilepsy. 

When the hysteria is accompanied by insomnia, excitement, and, in partic- 
ular, genital excitement and much agitation, moreover, when the patient is of 
robust frame, the bromide will give admirable results. On the contrary, when 
your patient is feeble and anaemic, manifesting her neurosis by gloom and 
tears, and the nerve-centres are depressed in their action (there being no geni- 
tal excitation), the bromide can do nothing but harm. The great inconven- 
ience of the bromide results from its depressant action on the nervous system, 
and patients submitted to this treatment experience such a physical and mental 
torpof that it is difficult for # them to apply themselves to their ordinary tasks. 

The acne eruption which often follows the continued use of bromide in 
large doses is a serious evil, especially to fashionable young ladies, who 
strongly object to see their faces disfigured with this rash, and sometimes 
refuse the remedy altogether. I know no means of preventing this bromide 
eruption, which results from the elimination of the bromide by the skin. I 
know that it has been claimed that the internal use of arsenic will prevent the 
eruption, but I have often given it for this purpose with no result whatever. 

As for the dose, this varies according to individuals, but, as a guide, you 
ought always to have recourse to an examination of the reflex sensibility of the 
velum palati, and your doses should be large enough to obtain, in most cases, 
anaesthesia of the pharynx. By way of caution, I would advise you not to 
give the bromide for a great length of time, and to occasionally suspend the 
treatment. For your guide, you have only to follow the evolution of the ner- 
vous manifestations. In most cases these manifestations are produced about 
the time of the catamenia; it is before, during, and after these periods that you 
ought to administer the bromide, and in such a manner that there may be in 
each month fifteen days of treatment and fifteen days of rest. 

Beside the alkaline bromides, other bromides have been recommended, 
such as bromide of zinc and bromide of camphor. 1 The latter has been much 
vaunted these late years, but its action is very uncertain, and it has no efficacy 
except in cases of genital excitement; as for bromide of zinc, this preparation, 
little employed in this country, has been highly spoken of by Hammond, of the 
United States, who advises it especially in epilepsy. Opium plays an im- 
portant part in the treatment of hysteria, and like bromide, has its advantages 

1 The bromide of camphor (C 10 H 15 BrO), was discovered and described by Swartz in 
1862. It is obtained by heating in sealed tubes a mixture of one part of camphor and two 
of bromine at the boiling point. When it is pure, bromide of camphor presents itself in the 
form of transparent prisms. Its taste recalls that of camphor and spirits of turpentine. It 
is insoluble in water but very soluble in alcohol and ether; it melts between 76 and 77 C, 
and boils at 274 . Bromide of camphor is administered in pills and in capsules, in the dose 
of 50 c. g. to two grammes in the twenty-four hours. (a) 



(a) Deneffe On mono-bromide of camphor. (Presse Medicale Beige. 1871.) 

Bourneville On the therapeutic employ of bromide of camphor. (Progres Medical. 1874-5-6.) 

Petrovitz, On bromide of camphor (th. de Montpellier, 1875. 

R. Lawson, Practit, 1875. 

Pathault On mono-bromide of camphor (th. De Paris, 1877). 



92 ON THE TREATMENT OF HYSTERIA. 

and disadvantages. It was my master, Bernutz, who, after Gendrin, extolled 
especially the opiate medication. He administered laudanum in the dose of 
two drops twice a day, and gradually increased the dose till forty drops were 
taken in the twenty-four hours. This treatment is mainly applicable to the 
asthenic forms of hysteria; I believe it useless and dangerous in the sthenic 
forms, and you plainly see the indications for the opium treatment are directly 
opposite to those for the bromide treatment, for opium has an exciting action 
on the nervous system, while bromide is depressant. Unhappily, this treat- 
ment by opium has another disadvantage, in the large doses which one is com- 
pelled to attain in these cases, and many hysterical patients become morpho- 
maniacs. In order to avoid these disadvantages, it has been proposed to sub- 
stitute chloral, but here again you encounter serious inconveniences, for the 
continued use of chloral in doses gradually increased is very detrimental. 

This question of dose in neuropathic patients is of the greatest interest; 
hysterical subjects present, as Huchard has well said, a veritable therapeutical 
ataxia. Sometimes they are poisoned by extremely small doses of certain sub- 
stances, and sometimes they experience no therapeutic effect from really enor- 
mous doses. It is well to bear this fact in mind when called to treat a hys- 
terical person. Do not forget, moreover, that there exists from the point of 
view of medicinal treatment, a moral influence of a direct and positive kind, 
and that here you will have occasion to witness the triumph of pills of mica 
panis, of potions of the extract of dandelion; in a word, of all those prepara- 
tions which act on the imagination alone. The history of medicine abounds in 
cases where, owing to the assurance with which they have been prescribed, 
these pills and these potions have had the most signal curative efficacy in neu- 
ropathic individuals. 

By the side of pharmaceutical treatment, and even above it, is placed bal- 
neotherapy, which comprehends three modes of application; baths, hydro- 
therapy, and mineral waters. Warm baths, and particularly prolonged baths, 
have a very happy influence in the treatment of nervous disorders, especially 
in the period of excitation, and Bernutz has greatly vaunted their effects. 
These baths ought to be of from one to two hours' duration, and the water all 
this time should be kept at the same temperature. The therapeutic virtues of 
these baths are augmented by adding infusions of aromatic plants, as melissa 
or valerian, of which medicated baths Beau speaks in high terms. The good 
effects derived from these medicated baths are explicable, not on the principle 
of cutaneous absorption — the skin with its epidermic covering does not absorb 
medicinal substances contained in baths — but entirely by the introduction 
through the respiratory passages of the odorous and volatile principles of the 
herbs employed. It has, as you are aware, been maintained that in order to 
obtain the therapeutic effects of valerian it must be administered, not by 
mouth but by inhalation. 1 

Hydrotherapy plays an important part in the treatment of hysteria; it 

1 Pomme has greatly extolled prolonged baths in hysteria;" he regrets that the day is 
not more than twenty-four hours long, because, that nOw, he is not able to give them as 
long as he would like. 



ON THE TREATMENT OF HYSTERIA. 93 

constitutes, with the bromides, the grand basis of the therapeusis of this dis- 
ease, but it is important that you should know how the cold water should be 
applied. It is advisable to employ douches at the beginning of the treatment, 
but always tempered douches. The effect on the nervous system of cold 
water is sometimes so violent in hysterical patients, as to determine such a 
state of suffocation that after enduring the first cold douche, they obstinately 
refuse to submit any longer to this treatment. It is well, then, to begin with 
tempered douches (about 25 to 30 Cent.), and to progressively lower the tem- 
perature of the water; and it is only when the system is habituated to this 
mode of treatment that you will be able to give cold douches, or rather alter- 
nating douches (douches alternately cold and hot). These last sometimes have 
too stimulant an effect and determine hyperexcitation; you must then return to 
tempered douches. In a word, in your hysterical patients, you ought always to 
begin with tempered douches, and then according to the periods of excitation 
or depression in which your patient is found, you should employ the stimu- 
lating action of the alternating douche, or the sedative effects of the tempered 
douche. You must avoid at first douching the heads of your patients; I have 
often seen the shower-bath on the head determine neuralgic pains of a severe 
nature, or quite persistent vertigines. The duration of the douche ought not 
to exceed thirty seconds. 

You will derive from hydrotherapy thus utilized, very beneficial results; 
cold-water treatment restores not only the sensibility of the skin, as Thermes 
has shown, but it also promotes the equilibrium of the functions of the nervous 
system, and nutrition in general. But in order to obtain these results satisfac- 
torily, it is often necessary to remove the patient from her family surroundings, 
and to place her in some hydrotherapeutic establishment, where the administra- 
tion of cold water is made with great skill and prudence. And this is a point 
on which Charcot has justly insisted. Mineral waters have a feeble part in the 
treatment of hysteria, and generally as it is the action of cold water that is 
sought, patients are sent to the hydrotherapic stations so numerous in the centre 
of Europe, and which especially abound in Switzerland and the Tyrol; stations of 
which Devonne and Aussee are types, and which, with the action of cold water, 
unite all the climatic conditions favorable to the treatment of affections of the 
nervous system. In France we have a thermal station which enjoys a certain 
repute in the treatment of nervousness, I refer to Neris; to these waters you 
may join those of Ussat, St. Sauveur, and Forges les Eaux. 

But, while on this subject of mineral waters, I must caution you against 
the employment of sea-baths in hysteria. I see many of my confreres send 
their hysterical patients to the sea- side; it is a bad practice. For my part, I 
have always seen sea-air and especially sea-baths, attended with such excitation 

• 

Beau and Bernutz advise warm baths of two, four, six, and eight hours' duration. 
Bernutz has seen, under the influence of baths six hours long, cataleptic attacks that 
have lasted six or eight months disappear completely. (Pomme, Traite des affections va- 
poreuses des deux sexes, Paris, 1883. Bernutz, art. Hysterie, in Nouveau Diet, de Med. et 
de Chir., 1873). 



94 ON THE TREATMENT OF HYSTERIA. 

physician by the name of Perkins ' grouped together all the facts from Galen 
downward, and propounded a medical doctrine which bore the name of 
Perkinism. But almost all of these facts were forgotten when Burq commenced 
that my patients were much the worse for it; so, in my opinion, the hysterical 
condition contra-indicates the employment of sea-baths. 

Electricity is doubtless an element of secondary importance in the treat- 
ment of hysteria; nevertheless, it renders us good service. It may, as we shall 
presently see, arrest the attacks, or diminish their number; it may also modify 
sensibility, like hydrotherapy. In these cases, it is especially to static electricity 
that you should have recourse, as it is this form of electricity, revived by Arthuis, 
and more recently by Charcot and Vigoureux, which gives the best results. It 
is here that you should make use of those general electric baths, those electric 
brushes, and those sparks which I described in my lecture on medical electricity, 
procedures which constitute what is called franklinization. But there is a kind 
of medication which has with electricity many points of contact. I refer to 
metallotherapy, on which I desire to dwell at some length. From the most 
remote antiquity, medicinal properties have been attributed to metallic plates, 1 
and plates of copper, lead, or gold, applied as veritable amulets to the skin, 
have had curative efficacy in certain nervous disorders, according to the state- 
ments of ignorant pretenders. About the end of the last century, an American 

1 The application of metallic plates or disks is of very ancient origin; Galen, Paul of 
Egina, Von Helmont, all made use of plates of lead as anaphrodisiac, and in the last 
century the amulets of Saturn were of popular usage in accouchements. Metallic gold was 
employed by Marcellus, Epicurus, Alexander of Tralles, Peter Albanus, as an external 
remedy for pains. Copper plates were employed by the contemporaries of Aristotle to 
assuage pain. In India they employ, as a therapeutic measure, alternately applications of 
pieces of gold and copper. Finally at the commencement of this century, Perkins in 
America, Frank of Vilna, Wichmann, and D'Espine made known facts where the application 
of metals modified nervous states. But all these facts had fallen into oblivion, when 
Burq communicated to the Academy of Sciences on the 4th of February, 1850, his memoire 
entitled, "Note to Serve as History of the Physiological and Therapeutical Effects of Metallic 
Armatures, or of Certain Metals on Paralysis of Sensation, or So-called Anaesthesia." 
Burq completed this work in his inaugural thesis of February 7th, 185 1. It was not, how- 
ever, till 1876 that the facts recorded by Burq were definitely recognized in the conclusion of 
a report made to the Society of Biology by Dumontpallier. (a) 



(a) Schiff, Arch, des sciences phys. et nat., Geneva, 1879, No. 3. Westphal, Berliner klin. Wochens., 
July 27, 1878, p. 81. Mader. Wiener med. Wochens., 1880, p. 681. Ost, Corresp. Bl. Schweiz Aerzte, 1880. 
p. 524. Sciamanna, Gaz. di Roma, June 1, 1878, p. 227. Parona, Ann. univ. de Med. et Chir., Oct., 1879, t. 
xlix, p. 336. Cennctt, Brain, Oct., 1878, p. 331. Eulenburg, Deutsche med. Woch., June, 1878, p. 151-327. 
Tuke, Metalloscopy and Expectant Attention (Journ. Ment. Sci., Jan., 1879, p. 508). Gradle., Metalloscopy 
and Metallotherapy (Journ. Ment. of Nervous and Mental Diseases, Oct., 1878, vol. 3, p. 781). Petit , La 
Metallotherapie ses Origines son Histoire, Paris, 188 1. Htichard, Traite des nervoses, p. 1128. Dujardin- 
Beaumetz, Des proprietes esthesiogenes de certains bois, appliques sur la peau (Bull. Gen. de Ther., t. 99, 
1880, p. 97). Hammond, Clin, lecture on Metallotherapy and Expectant Attention, in Philadelphia Med. and 
Surg-. Rep., April 3, 1878. Galen Book V. Paul of Egina, Book vii., sec 3. Peter Albanus, vide Spregel, 
vol II. p 203. Wichmann Ideen zur Diagnostik. Hanover 1800, t. 1. p. 159. D. Espini, Observations de Med. 
Prat. Annecy, 1838. Burq Academie des Sciences, 14th Feb., 1858 (these inaugurale). Dumontpellier Gaz. 
Med. de Paris, 1877, p. 241, etc. Oscar Jennings. Comparisons of the effects of different treatments in 
hysteria, preceded by a historic sketch of metallotherapy. These de Paris, 1878. No. 335. 



ON THE TREATMENT OF HYSTERIA. 95 

his experiments, and it is to him that we owe the valuable discovery of metallo- 
therapeutics and the indications which flow from it. The first tentatives of this 
experimenter were made in 1850, and it was not till nearly thirty years later, 
after the reports made to the Society of Biology, in 1877 and 1878, by Dumont- 
pallier, that this method entered definitely into the domain of current practice. 
Burq affirmed that metals applied to the skin restore sensibility, force, and 
animal heat, and that according to circumstances little understood, the curative 
metal varies with individuals. Such a person is sensitive to gold, another to 
iron, another to copper, etc. etc., and from the results of these external applica- 
tions of metals he drew conclusions as to the internal administration of metallic 
preparations, which had the same property of restoring sensation and bodily 
heat; in a word, metalloscopy led to metallotherapy. 

The experiments made in this direction by the Committee of the Society 
of Biology, under the supervision of Charcot and Dumontpallier, brought to 
light a great number of new facts; they showed that troubles of sensibility, 
limited to one-half of the body, might, under the influence of these metals, be 
transferred to the half not affected, thus illustrating what has been described as 
the law of transfer? 

1 Perkins was a physician who practiced about the end of the 18th century in Plainfield, 
N. J., and who died in 1800, in New York. He was the inventor of an instrument whose 
essential part consisted in the presence of needles of different metals, some of steel and some 
of brass; in moving these needles over the painful parts of the skin it was claimed that pain 
might be made to disappear. This mode of treatment, brought from America to Denmark, 
had a great reputation. Heroldt and Rafne, physicians of Copenhagen, perfected this mode 
of practice, and employed needles of silver, of zinc, of bismuth, of copper and of lead and 
even of ebony and of ivory, and noted that the latter had but little effect. The name of 
Perkinism was given to this therapeutic procedure, (a) 

2 Huchard has given an excellent description of the phenomena which are observed as 
the result of metallic applications, and this is the way he classes them: 1. Return of 
sensibility. 2. Phenomena of transference. 3. Consecutive oscillations. 4. Provoked 
anaesthesia. 5. Phenomena of inhibition. 

1. The return of general sensibility takes place from ten to twenty minutes after the 
application of the metallic plates, in a zone of several inches around the plate. It is 
announced by prickings, formications, and elevation of temperature. Moreover, pricks which 
were made before the application of the metallic plates, are red and bleeding. The muscular 
force returns at the same time as the sensibility. 

2. Transference is produced symmetrically in homologous points, and sensibility to 
the temperature and the muscular force may also manifest phenomena of transference. 

3. The consecutive oscillations show themselves after the applications of the metal, and 
alternate returns of aesthesia, and anaesthesia are produced in the point where the metallic 
application has been made and in homologous points. 

4. Just as one can produce aesthesia one can also provoke anaesthesia. 

5. As for the phenomena of inhibition, they are produced by fixation of the phenomena 
of aesthesia or of anaesthesia, by the adjunction of neutral plates to active plates, (b) 



(a) Alibert's Elements of Therapeutics, Vol. II.. page 521 

(b) Huchard, Traite des Levroses, Paris 1871, page 123. 



96 ON THE TREATMENT OF HYSTERIA. 

It was also discovered that metals were not the only bodies capable of 
modifying sensibility, and the number of aesthesiogenous substances, as they 
are to-day called, continually increases. Charcot and Regnard, taking up again 
the first experiments of the last century, noted the aesthesiogenous properties of 
magnets. 1 Vulpian showed that electricity, applied to a very circumscribed 
part of the cutaneous surface, possessed the same properties. Then Grasse, 
with the vesicatory; Thermes, with cold water; Parona, with metallic salts; 
Seure, with dried collodion and cellulose; and Lannois and Huchard, with 
jaborandi, obtained the same results. 2 I myself, in my hospital service, have 
shown, as Jourdanis had previously done, that wood, like metals, can restore 
sensibility, and that, just as there exists active and inactive metals, there exist 

1 Magnets have been utilized in therapeutics for many years, and without speaking of 
antiquity, when magnets were applied internally to cure nervous affections, in the 17th 
century they were employed in the crisis of hysterical suffocation. Father Hell constructed 
armatures which were used in France by the Abbey Le noble, Descemet, La Condamine and 
Arquier. In their report to the Royal Society of Medicine, in 1779, Andry and Thouret 
showed that the application of magnets is especially useful in diseases which have for their 
principal cause exaggerated action of the nerves, such as spasms, convulsions, and acute 
pain. 

Laennec employed magnets in certain spasms. Charcot, Debove and others have 
especially studied the action of magnets, (a) 

2 The number of aesthesiogenous substances is considerable, and, apart from elec- 
tricity, it has been noted that the following substances may bring back sensibility: 

1. Collodion. Seure has observed the action of collodion as an aesthesiogenous agent; 
he makes use of dried plates of collodion which he applies to the skin. 

2. Pilocarpine. Grasset, Lanois, and Huchard have caused sensibility to return by 
practicing sub-cutaneous injections of pilocarpine. 

3. Plates of bronze and of various materials. Plates of bronze, according to Wesphal, 
are aesthesiogenous. Parona has employed minerals, such as sulphate of iron, carbonate of 
lime, sulphate of lime, and fluoride of calcium, and by this means has brought back sensi- 
bility. On the other hand, sulphate of baryta and mica do not posess any aesthesiogenous 
property. 

4. Hydrotherapy. Thermes has observed that the employment of cold water and of 
ice restores sensibility. 

5. Vesication. Sinapisms like vesicatories may restore sensibility. Grasset has insisted 
on these facts, which were before pointed out by Barthez, Buzzard, and Russell Reynolds. 

6. Sonorous vibrations. Sonorous and mechanical vibrations possess aesthesiogenous 
properties. Maggiorani went so far as to maintain that it is by this molecular action that is 
produced the action of the metals, and of all aesthesiogenous bodies. (5) 



{a) Hell. Med. Prat. Bibl. de Murray t. xi, 1779, Gottingen. Andry and Thouret, Memoires sur le 
Magnetisme. (Mem. de la Soc. Royal, de Med. 1879, t. iii., p. 521, 638.) Laennec, Treatise on Mediate 
Auscultation, 1828, t. ii., p. 69. Maggiorane, la Magneteli nervosi, Milan, 1869. Proust et Ballet, Congres 
d' Amsterdam, Nov. 23d, 1879 et Jour, de Ther., 1879. Debove soc. Med. des hop., 1880, and Gaz. hebd. de Med. 
et Chir, Sept. 19th, 1859, P- 903. 

(i>) Beard, Brit. Med. Jour. Sept. 6, 1879, t. ii., p. 373. Seure, Researches on the Electrical properties 
of dried Collodion. (Acad, des Sciences, 1880.) Maggiorani, Bull, de Ther., 1 49, p. 100, 1880. "On 
the Physical Effects of Sonorous Vibrations." Gresset, Return of General and Special Sensibility in a 
Hemiansesthetic Patient, after the use of an infusion of jaborardi (Jour, de Ther., No. 1,1880). Lannois, 
Jour, de Ther., April 10, 1880. Huchard, Jour, de Med. et Chir. Practiqu^s, Dec, 1882, p. 541. 



ON THE TREATMENT OF HYSTERIA. 97 

also woods with variable action, so that, alongside of metallotherapy, we have 
xylotherapy? 

The method invented by Burq,and called Burquism, gave rise to numerous 
experiments which were not limited to the school of Salpetriere. In Germany, 
Westphal, Eulenburg, Mader, Ost; in Italy, Maragliano, Sepelli, Sciamanna, 
Parona; in England and America, Thompson, Hughes Bennett, Tuke, Donkin, 
Sigerson, Beard, Gradle, and Hammond, repeated the experiments of Burq, 
and to-day we have documents sufficiently complete, and sufficiently numerous 
to enable us to appreciate this method at its just value. 

First, how are these metallic applications made? In a very simple manner. 
All that you have to do, is to apply to the skin of your patient certain metallic 
plates as directed by Burq, or what is much more handy, pieces of money, and 
to-*watch the phenomena that occur after this application, which may have a 
variable duration and extent; thus, for example you can make bracelets or 
girdles of these coins, to be worn for a time around the diseased part. We 
utilize in the same way disks of wood or of dried collodion; as for magnets, you 
should use large ones, of considerable power, and a weight of at least twenty 
pounds. 

Internal metallotherapy may be tried; i. <?., having once recognized the 
active metal, you may give some pharmaceutical compound containing a salt of 
the metal in question. On this principle, chloride of gold 3 has been given in 
the dose of one to two centigrammes a day, nitrate of silver in the dose of one 
centigramme, the salts of zinc, and especially oxide of zinc, in the dose of twenty 
to thirty centigrammes, the salts of copper, the salts of iron, etc. 

What are you to think of metallotherapy? Are there certain genuine facts 
at the basis of this medication, or is it a species of dupery ? After the report 
of Dumontpallier to the Society of Biology, medical men here in France and 
abroad were divided into two parties, one party maintaining that metalloscopy 
had no serious basis, and that a certain effect wrought on the imagination of 
hysterical patients, "expectant attention," as it was called, explained all the 

1 Hoggard had already shown the aesthesiogenous action of different kinds of wood as 
illustrative of "Perkinism;" in 1878 Bennett noted the action of various woods on the 
cutaneous sensibility. Dujardin-Beaumetz and Jourdanis have in their turn proved that there 
exists a series of active and inactive woods. The active woods are thuja, rosewood, mahog- 
any, pitch-pine, butternut, maple, and apple tree; the most active of all is cinchona. Ebony 
wood, ash, poplar, and sycamore have no aesthesiogenous property, (a) 

2 Chloride of gold is obtained by putting in contact metallic gold with nitro-hydro- 
chloric acid; a solid and crystalline mass is thus obtained, yellowish red, and very deli- 
quescent. This chloride of gold had been before employed by Chrestien, of Montpellier, 
by frictions on the tongue and gums, in the dose of one centigram. It is a caustic and an 
emeto-cathartic which produces in the dose of 5 to 10 centigrams repeated vomiting. Of 
late it has been advised to use not chloride of gold, but gold leaf prepared for gilding; with 
this pills are made and given to the patient. 



(a) Bennett, Brain, Journal of Neurolgy, October, 1878. Page 331. Dujardin-Beaumetz, On the aesthe- 
siogenous properties of certain woods. (Bull, de Ther. t. 99, 1880, p. 97.) 
§7 



98 ON THE TREATMENT OF HYSTERIA. 

phenomena observed; others, on the contrary, maintained the positive remedial 
power of the metallic applications, apart from any "moral" effect. 

To-day, gentlemen, unless we except a few obstinate individuals whom 
nothing can convince, everybody seems to be agreed that there do exist 
aesthesiogenous substances which restore or transfer sensibility, or cause to dis- 
appear certain nervous troubles, not only in the case of neuropathic persons, 
but also in certain lesions of the nervous system. But while admitting the 
truth of the facts adduced by Burq, it must be borne in mind that from the 
exclusive point of view of therapeutics, this method has not realized all that has 
been expected of it. Yes, the application of metals to the cutaneous surface 
has sometimes caused sensory troubles to disappear; it has even cured certain 
contractures, but these are exceptional facts, and the results obtained are tem- 
porary. In short, metallotherapy merits a very humble and secondary place in 
the treatment of hysteria. 

I have experimented much with metallotherapy in my hospital service. 
I have observed facts very curious, very strange, the physiological explanation 
of which seems to me, at present, impossible to give; but my hysterical patients 
have not derived from this method any definite or lasting benefit, and they 
generally go away in about the same condition as when they entered. I add 
that there is a certain number of anaesthetic hysterical patients on whom 
metallotherapy has no effect, especially when the loss of sensibility is general. 
At the same time I admit that there is between the convulsive manifestations 
of hysteria and disturbances of cutaneous sensibility a very intimate correla- 
tion, and when you cause the latter to disappear, you often cure the former. 
We have, then, every interest, from a therapeutic standpoint, in restoring sensi- 
bility to the skin, and as metallotherapy is one of the means for attaining this 
end, in spite of the temporary and often uncertain results which are obtained, 
it is not best to abandon this mode of treatment, which is attended with no 
danger, and enables us, in certain cases, to obtain alleviation, if not permanent 
cure 

I have now finished the general treatment of hysteria, and come to the 
second part of my subject, the treatment of the attack. When a hysterical 
subject has an attack, you ought instantly to place her on a small bed or cot 
convenient for passing around; you should remove all tight clothing and every- 
thing which can cause constriction, and then proceed to employ the various 
means in repute for putting an end to the paroxysm. Formerly they were in 
the habit of pouring or dashing cold water on the face of the patient. 
Cruveilhier, 1 reviving an ancient practice, made the patient swallow large gulps 

1 This is the way Cruveilhier proceeds : At the moment when the jaws cease to be 
contracted, he introduces the edge of a teaspoon, which keeps the mouth open; then seizing 
a bottle full of water, he pours the water from a certain height into the mouth of the patient; 
this he continues to do for some time. The first mouthfuls are generally rejected, but the 
spasm of the throat ceases, the patient can swallow, and soon comes to herself. The water 
never in these cases penetrates the larynx. Anstie recommends to make strong pressure 
over the abdomen, in order to force the uterus into the pelvis, for it was supposed at this 
period that it was the uterus itself which, by its position in relation to different organs, 



ON THE TREATMENT OF HYSTERIA. 99 

of cold water, but lately we have found a quicker and surer method — that of 
compression of the ovary. 

The ancients, who attributed to the uterus a preponderating role in the con- 
vulsive manifestations of hysteria, had already proposed various manoeuvres, 
which consisted in compressing the womb, in putting in the vagina odorous 
substances for the purpose of acting directly on the womb, or in various meas- 
ures for ridding the womb of purulent humors which it was supposed to con- 
tain (such even as titillation of the external genitals and neck of the womb, as 
recommended by Galen, Forestus, and Ambroise Pare). Areteus, Aetius, Sau- 
vages, Astruc, and others dwell long on the advantages of various procedures; 
you know even that external compression is of vulgar usage, and you often see 
persons make pressure and even sit upon the belly of patients to arrest con- 
vulsive seizures. But this practice has been reduced to method since the 
labors of the Salpetriere, which have shown us that one of the most frequent 
hysterogenous points is the ovarian region, and that it suffices to compress 
this region, either on the left or on the right side, to bring on an attack or to 
cause one to disappear. 

This is the way to practise compression: the patient being placed on a 
hard, low bed, the physician, standing by her side, plunges the closed fist per- 
pendicularly into the sensitive ovarian region. It is necessary at first to em- 
ploy considerable force to overcome the contraction of the abdominal muscles, 
but once this obstacle is overcome, the hand penetrates the iliac fossa, and the 
spasms cease if the pressure be continued for a certain time. 

Certain apparatuses have been constructed, called compressors of the ovary, 
models of which I now show you, and the most simple of which is that of Ferre, 
which consists in a hernia truss, terminated by a conical pad, which is applied 
over the sensitive ovary. This apparatus, they say, will prevent the recurrence 
of a convulsive attack; I avow that I have never made use of these compress- 
ors, and therefore know nothing about them. Surgeons have even gone further: 
they have proposed ablation of the ovaries, and we have seen Battey and 
Peaslee perform this spaying operation in cases of hystero-epilepsy. 1 

determined the attack of hysteria, and that all that was necessary, in order to cause the 
attacks to disappear, was to press the uterus into its normal position. Recamier, nearer our 
epoch, counselled an analogous procedure in the application over the abdomen of the patient of 
a pad, with which he made very energetic pressure. Among the common people this practice 
has been known for a longtime, and we see in the history of the Convulsionists of St. Medard 
the account of women on whose bellies persons jumped, or even placed large stones; some 
even were in the habit of striking hard blows, frequently repeated, with iron bars or heavy 
clubs. Gustave Sadrain prefers compression of the ovary to galvanism in the treatment of 
the hysterical attack (a). 

1 To Battey is due the chief credit of this operation, now known as Battey's operation. 
There are on record three cases, at least, where ablation of the ovaries resulted in permanent 
cure of hystero epilepsy, recurring at the menstrual period; those of Battey, Peaslee, and 
Braun-Ferwald. Vide Battey, Atlanta Med. and Surg. Journal, September, 1872, and 
American Practitioner, October, 1875. Also, Peaslee, Transactions of the Amer. Gynaecol. 
Soc, p. 340, 1876, and Hegar, Die Castration der Frauen, etc., 1878, pp. 136-138. 



{a) G. Sadrain, Etude sur le traitement des attaques d'hysterie. Th. de Paris, 



100 ON THE TREATMENT OF HYSTERIA. 

Unfortunately, not all hysterical females have ovarian troubles, and in such 
cases the method of compression is not applicable; you can then advantageously 
have recourse to electricity. 

Vigouroux and Richer have shown that galvanic currents, one of the reo- 
phores being applied over the front, and the other over some other part of the 
body, diminish the duration of attacks of hysteria; moreover, if you suddenly 
reverse the direction of the currents, which is easily done with the commutators 
of Trouve and Gaiffe, the attack ceases immediately. You must not exceed 
six to ten milliamperes, for if you do, you will determine severe head-troubles. 

In fine, inhalations have been proposed of odorous substances; the number 
of these is considerable, and the ingredients very strange, from deer's horns and 
goat's feet, to the odors of candle snuff, of the hairs of men and of animals, and 
the feathers of partridges and woodcocks; the ordinary perfumes, benzoin,musk, 
ambergris, etc., have all been advised. To-day we discard all these things, and 
recognize but a very few medicinal substances, whose inhalation has a beneficial 
effect on hysteria; these are ether, chloroform, and especially nitrite of amyl. 
Ether and chloroform may render you some service. I have not, however, been 
very successful with these anaesthetics. The attacks are prolonged, and they are 
almost sure to reappear when the anaesthetic sleep has passed off. Nitrite of 
amyl, with which Bourneville has made so many experiments in hysteria, cer- 
tainly diminishes the intensity and the frequency of the convulsive paroxysms. 
You must not, however, resort to it, except during the attacks, for at other 
times it may determine convulsive seizures. When giving the nitrite of amyl, 
you pour five or six drops on a handkerchief, and cause the patient to inhale, 
them. 

I shall finish this lecture by giving you, with as much brevity as possible, 
some indications respecting the treatment of certain manifestations of hysteria. 
The contractures are the most rebellious of symptoms in hysteria, and nothing 
is more painful than to see young women afflicted with various contractures, 1 
which make life a torture. These contractures appear suddenly after an attack, 

1 Hysterical contractures, known for a long time, have been thoroughly studied the 
last few years by Charcot, Bourneville, and Voulet. 

They may be transient and come on during the attacks of hysteria; artificial, and pro- 
voked by mechanical excitations, or permanent, and appear in the interval of the attacks, or 
after the attacks. 

We shall here concern ourselves with only the permanent contractures. They may 
affect all the muscles, take on the hemiplegic or paraplegic form, strike singly a muscle or a 
whole group of muscles. They occur ordinarily suddenly and without apparent cause; some- 
times, however, in a hysterical patient affected with flaccidity of the paralyzed limbs or even 
in a subject who has never yet presented symptoms of hysteria, a slight traumatism, or even 
muscular exertion suffices to give rise to contracture. 

Contractures are always accompanied with a disturbance of sensibility, whether anaes- 
thesia or hyperesthesia of the skin. The muscles affected are in an absolute rigidity which 
the most energetic efforts do not succeed in overcoming, and which does not yield even 
momentarily except to chloroformization carried very far. The duration of the contractures 
is indefinite. They may last months, years, and cease spontaneously without apparent 
cause, or under the influence of some mental emotion, leaving the parts in a state of perfect 
integrity. The contracture may also persist indefinitely, and in this case the autopsy some- 



ON THE TREATMENT OF HYSTERIA. 1G1 

and may disappear as suddenly after another attack. This is an occurrence which 
is witnessed in all the manifestions of hysteria, and you have seen a fine illustra- 
tion of it recently in our wards. I refer to that young hysterical girl who en- 
tered the hospital for gastric troubles, and was suddenly taken with contractures, 
which disappeared after a convulsive attack, which we induced by chloroform, 
given to anaesthesia. This is then a means of cure which you can employ in 
hysteric manifestations of every kind. 

Electricity, metallotherapy, and cold douches have sometimes caused these 
contractures to disappear; in other cases they have resisted every kind of treat- 
ment, and have persisted for months and even for years. But whatever may be 
their intensity, they disappear momentarily under the influence of anaesthesia, 
when carried to completeness, or of energetic compression of the contractured 
member. 

By the side of these contractures we must place paralysis, which appears 
and disappears with extreme rapidity. This paralysis, which often affects the 
inferior members, presents this curious peculiarity that it is always accompanied 
by trophic disturbances, and you will sometimes see hysterical paraplegics recover 
in an instant the integrity of their motor functions. It is here that electricity 
and hydrotherapy may give unlooked for curative results. 

times discloses a sclerosed state of the lateral columns of the spinal cord. Bourneville and 
Voulet divide contractures into partial contractures and contractures of the members. 

The first embrace more particularly: (i) a half of the face; the muscles of the eye are 
not spared, whence result troubles of the accomodation; (2) the muscles of the upper maxilla 
(trismus); (3) the tongue, and sometimes the velum pendulum and oesophagus; (4) the mus- 
cles of one side of the neck (hysterical torticolis, which is one' of the most frequent manifes- 
tations in infantile hysteria); (5) the muscles of the organic life, the choledic duct, whence 
icterus; the sphincter vesicae whence retention of urine, etc. 

The contracture of the the members takes on several forms; monoplegia, hemiparaplegia, 
paraplegia and hemiplegia. The contracture of an upper limb is quite rare; in these cases 
the limb is in a state of flexion, the arm adducted, the forearm supinated and half bent on 
the arm, the hand flexed on the wrist, the thumb bent into the palm of the hand and covered 
by the fingers strongly flexed. In the contracture of the lower extremity it is extension 
which predominates. When there is paraplegia, the member is in forced adduction; the 
knees are brought together, and the feet present a characteristic attitude (hysterical club 
foot); the heel is elevated, the tendo achillis is prominent and on the stretch, the dorsal 
aspect of the foot turned outwards, the plantar aspect is hollowed out and looks inward and 
backwards, the external malleolus becomes very prominent. The extremity of the foot is 
strongly depressed and the toes are flexed (Richer). It is quite rare to observe the crossed 
form in which the upper member of one side and the inferior member of the opposite side 
are affected. 

What is sufficiently frequent is the periarticular form in the foot, and especially the 
hip. 

When the muscles of the foot are affected, you observe, ordinarily, the variety of club 
foot known as varus equinus, sometimes the variety of direct varus. 

In the hip contracture of the muscles of the pelvi-trochanteric region gives rise to 
hysterical coxalgia, spasmodic and nervous. 

In these cases, as in all those where there is any doubt if it be hysteria or not, it is 
well to have recourse to chloroformization, to clear up the diagnosis; the hysterical contrac- 
tures disappearing under the influence of the anaesthetic. 



102 ON THE TREATMENT OF HYSTERIA. 

As for the troubles of sensibility, 1 I will not repeat what I said while treat- 
ing of the neuralgias, and I will only say a word or two about anaesthesia. This 
is, as you know, a disorder almost constant in hysterical women, but one which 

1 Disorders of sensibility are quite frequent in hysteria, but those which are observed 
are generally cutaneous disturbances; hyperesthesia and anaesthesia. Hyperesthesia or 
dermatalgia, which is most often met in acute hysteria, according to Briquet, may present 
several degrees; touch acquires such a sensibility that the lightest contacts, even a breeze of 
fresh air, provoke a disagreeable impression, and in some cases even pain. The dermatalgia 
may commence by a limited point and from thence spread over the whole body; it may also 
be localized and affect half the body, the anterior or the posterior aspect, one or several 
limbs. It is accompanied also, in some cases at the beginning, with agitation, cerebral exci- 
tation, numbness and formications in the limbs, sometimes also with pains in the subjacent 
parts. Limited to the mammary region, it may provoke a severe pain in the gland and 
simulate a grave disease. Localized in the hand or foot it prevents prehension or walking; if 
it reaches the thorax it hinders respiration; if it is in the vulva and the entrance of the 
vagina, sexual relations become impossible. Hyperesthesia sometimes co-exists with anes- 
thesia in certain points; hyperesthesia of one side of the body, anesthesia of the other. The 
superficial muscles are frequently affected; in 430 cases of hysteria, Briquet found only 20 
that were exempt from muscular hyperesthesia. Pressure, the lightest touch provoke pain, 
and this pain resides in the muscle itself, and is seated especially at the points of attachment 
of the muscles. Myoxalgia is peculiar to hysterical patients; it appears after an attack of 
convulsions, or slowly and gradually in anemic patients and those who are a prey to disap- 
pointments. It is not accompanied by any inflammation, nor by any muscular lesion. Its 
duration is variable; it ceases with the causes which have produced it, or under the influence 
of an appropriate treatment. Cephalalgia, considered by some physicians an a neuralgia, a 
migrane, is, according to Briquet, a muscular hyperesthesia; it is characterized by painful 
points on the forehead, on the temples, on the occipital region, on the top of the head. 

The clou hystrique is ordinarily seated on the vertix or the anterior angle of the parietal 
bones; it occupies a variable extent, being as large as a two franc piece, or even a little 
larger; the pain is sometimes sufficiently violent to cause the patient to cry out, and is com- 
pared to the sensation of a hot iron or a nail bored into the head. Epigastralgia is extremely 
frequent (317 cases out of 358 have been observed by Briquet); it may have its seat in the 
recti muscles of the abdomen and accompany gastralgia. It generally precedes the attack of 
hysteria, augments during the paroxysm and persists some time after; it is intense and is 
aggravated by pressure, walking, coughing, and moral emotions; it hinders muscular move- 
ments and respiration. Rachialgia or hyperesthesia of the muscles of the spinal column, is 
equally frequent (out of 430 cases it has been observed 306 times by Briquet). Like epigas- 
tralgia, it is generally seated on the left, and oftener in the upper half than in the lower half 
of the vertebral region. The pain may be brief and insignificant, or it may be permanent 
and so severe as to simulate Pott's disease of the spine, or some other spinal affection. 
Pressure awakens this pain, or exasperates it to such a degree as to provoke suffocation, 
dyspnoea, palpitations, a sense of strangulation in the throat, and constriction of the glottis. 
Plueralgia is very common in hysterical patients (out of 300 cases Briquet observed 233); it 
is very rare in men. It extends half the length of an intercostal space, starting from the 
vertebral groove, or it seems to be a continuation of the rachialgia and terminates in front 
being confounded with epigastralgia. It occupies ordinarily a space of four or five fingers' 
breadth on a level with the 5th, 6th, 7th, and 8th ribs. It is more common on the left side. 
The pain is either very light or very intense, and is exasperated by pressure, by cough and 
by movements. Under the name of ccelialgia Briquet describes hyperesthesia of the mus- 
cles which compose the circumferance of the abdominal cavity, in front and behind; it exists 
in half of the cases; and it is frequently seated in different parts of the anterior wall. Hyper- 
esthesia of the muscles of the anterior part of the thorax constitutes thoracalgia. It is very 
rare. Hysterical patients suffer from arthralgia and this pain is developed in persons long 



ON THE TREATMENT OF HYSTERIA. 103 

gives them so little trouble, that a person whom you observe for the first time 
will hardly call your attention to this loss of sensibility. I have seen patients 
presenting the strangest disorders of sensibility. I was first to observe what I 

subject to neuroses; such as dental, facial, intercostal, lumbo-abdominal, coccygeal neural- 
gias. Rarely there is sciatica. According to Briquet, true neuralgias are infrequent in hysteri- 
cal persons, and appear rather as a complication than as direct effects of hysteria itself. 

The hyperesthesia may also attain the organs of special sense, which thus acquire 
extra acuteness. 

When the hyperesthesia affects the larynx and the upper part of the trachea it gives 
rise to the hysteric cough, to pseudo-croupal suffocation, and to asthma. The hysteric 
cough, more common in girls than in women who have exceeded thirty years of age, is 
never a primitive symptom. It may be continuous and only cease during sleep, or come on 
in paroxysms and last only a few hours. The hysteric cough may persist for months or even 
for years, and go away, suddenly or gradually. The pseudo-croupal suffocation is quite 
rare, yet has been so intense that tracheotomy has been practiced for its relief, as in two 
instances by Michon and Velpeau. The asthma (uterine asthma of Von Helmont) is never 
permanent, often disappears suddenly, and frequently alternates with some other hysterical 
phenomenon. 

The hyperesthesia of the digestive passages gives rise to gastralgia, and to enteralgia. 
The gastralgia may be one of the first symptoms of the hysteria, and it is seldom that it 
appears for the first time before the age of twenty-five. Patients begin by losing their appetite, 
then they have curious longings; eat clay, earth, charcoal, or have singular antipathies, and 
cannot eat such and such kinds of food. In other patients vomiting constitutes the predomi- 
nant symptom; they cannot keep down any kind of nourishment, and vomit it before it has 
undergone the least digestion. 

The gastralgia may completely destroy the appetite, may excite it or pervert it. When 
the patients eat, it is not rare that the ingestion of food causes a severe pain which is not 
quieted till they vomit. This leads them to refuse all nourishment, and it is quite likely in 
some of these cases that the suffering and inanition may be sufficient to cause death. At the 
autopsy no lesion of the stomach is found. Like all the hysterical symptoms, the gastralgia 
is under the influence of mental emotion. It may cease abruptly, and be replaced by some 
other phenomenon. Enteralgia is quite rare; Briquet has noted it but 20 times in 400 
patients. It is characterized by quite sharp colicky pains, appearing and disappearing suddenly, 
and accompanied by flatulent distension of the belly. At the same time constipation is noted, 
and this sometimes so great that patients will pass weeks without going to stool. Other hyper- 
esthesias have also been met with; nephralgia, very uncommon; cystalgia and hysteralgia 
of the body or neck of the womb. Anesthesia is common in hysterical persons; it may 
affect the skin, the sense organs and the muscles. It is general, unilateral, or it occupies 
only a limited portion of the integument; it is complete, that is to say that it is accompanied 
with abolition of the sense of touch, temperature and pain; or it is incomplete. It may 
appear suddenly, before or after the attacks of hysteria; sometimes also it comes on after a 
pronounced hyperesthesia. Generally, anesthesia shows itself insidiously, the patient not 
even being aware of it till the physician discovers it. 

When the anesthesia is complete, you may even transfix the limbs with a sharp instru- 
ment and the patient experiences no pain, his features are impassive, and the puncture gives 
little or no blood. 

These phenomena explain the self-mutilations practiced by certain hysterical persons; 
they account also for the attitudes of the convulsionists of Saint Medard. 

Complete anesthesia is ordinarily accompanied with a lowered temperature, a retarded 
capillary circulation of the anesthetic part, with formications and numbness in the neighbor- 
ing parts, and a muscular weakness appreciable by the dynamometer. 

When the anesthesia is very extensive it may be complicated with cephalalgia. What- 
ever part it may affect, it never occupies but the localities innervated by nerves of the cerebro- 



104 ON THE TREATMENT OF HYSTERIA. 

have described as autographic women,' 1 and always it was the attentive examina- 
tion of the patient, and never her declarations, which enabled me to detect 
these disorders. 

At the same time the troubles of sensibility are important from the point 
of view of treatment, because when they disappear it may be affirmed that the 
patient will have no more attacks of hysteria. There exists, as I stated before, 
an intimate relation between the troubles of cutaneous sensibility and the con- 
vulsive phenomena. Metallotherapy, static electricity, the application of mag- 
nets, in short, all sesthesiogenous substances, may restore this sensibility, but 
generally this restoration is momentary. 

Troubles of the special senses have been noted, and especially of sight- 
Charcot has pointed out the alterations of vision in hysterical patients, and I 
have myself observed, with Dr. Abadie, a very curious case of sudden amau- 

spinal axis; it never affects those regions which receive their nerves from the great sympa- 
thetic principally, such as the lungs, the digestive tube, the heart. The most frequent form 
of hysterical anaesthesia is the hemi-anaesthesia, which affects the head, the limbs, the trunk 
of one side. 

It is always accompanied with muscular enfeeblement of the same side, and often with 
a lowering of the temperature. It affects all the modes of sensibility; sensibility to touch, 
to pain, to temperature; the organs of sense, the sight, the smell, the taste, the hearing are 
alike involved. On the part of the eye, you may observe amblyopia, achromatopsia, 
amaurosis. The two eyes may be affected. Sometimes only one is involved, and in this 
case, the well eye supplies the place of the other, and the patients make little account of their 
affection. The amblyopia is habitually accompanied by general achromatopsia; violet is the 
first color to disappear, then green, red and finally blue. 

Amaurosis may appear suddenly after an attack of hysteria (Briquet), or without any 
precursory sign independently of the attacks (Landouzy). Hearing is more rarely affected. 
As for the sense of smell; loss, complete or partial, of olfaction has been observed. 

The loss of sensibility is oftener partial. On the part of the mouth, the buccal mucous 
membrane is sensitive on one side, insensitive on the other; one-half of the two borders of 
the internal aspect of the cheeks, of the palatine arch of the velum pendulum, of the gums. 

Sapid substances are tasted only on one side, and in consequence of the anaesthesia, 
mastication is performed badly. 

Sometimes a complete insensibility of the velum pendulum palati has been observed, 
titillation provoking no reflex action. The duration of the anaesthesia is variable; it may be 
temporary or continue months and even years; it ceases with the other hysterical accidents, 
or under the influence of treatment, such as the application of aesthesiogenous agents. 

1 Dujardin-Beaumetz reported to the Societe des Hopitaux, at their meeting on the nth 
of July, 1879, tne nrst case °f an autographic woman. In this patient it sufficed to trace on 
the skin characters or lines, to see developed at the end of a few minutes a salient gyrus, 
corresponding very exactly to the tracings, which remain for some time, and which, at first 
limited and strongly defined, spread more and more, to be effaced at the end of four or five 
hours. The characters so traced were sufficiently prominent so that a wet-proof could be 
taken from them, as was done for the museum of the Hospital St. Louis. 

Since the communication of Dujardin-Beaumetz the number of autographic women has 
considerably increased, and this same modification of the vaso-motors has been found, not 
only in hysterical persons, but also in men and women free from all nervous diseases. This 
symptom is an urticaria, limited to the point of the skin on which the markings are made. 
(Dujardin-Beaumetz, Note sur les troubles vaso-moteurs de lap eau observes sur une hysteri- 
que, femme autographique, Bull, et Mem. de la Soc. Med des Hopitaux, t. xvi. 2e Serie,i879, 
p. 197.) 



ON THE TREATMENT OF HYSTERIA. 105 

rosis in a hysterical female, and which was speedily cured by the metallic ap- 
plications. 1 

Gastric hysteria is one of the most formidable phases of this neurosis, for 
it interrupts nutrition, and eventually brings about such disorders as even to 
cause death. By the term gastric hysteria is understood all the gastric and in- 
testinal disturbances which are observed in hysterical patients, from anorexia 
to incoercible vomiting. These vomitings may occur under two circumstances; 
either they succeed to that strange anuria, described by Charcot 2 , or else they 
come on without any antecedents sufficient to account for them. In the first 
class of cases you ought to respect these vomitings, as they are uraemic; in the 
second you ought to endeavor to arrest them. To the therapeutic rules which 
I gave you when speaking of the treatment of vomiting, I now add artificial 
alimentation (gavage) and electricity. Forced feeding has given me excellent 
results in certain cases, when used at the onset of the attacks. Ballet has ob- 
served similar facts in the service of Charcot, and you will find in the excellent 
thesis of my pupil Deniau a certain number of observations of a like kind, 
cases occurring in my hospital service. At the same time, if you expect suc- 
cess from "gavage," you must begin the treatment at a period not far removed 
from the inception of the gastric troubles, for, as Debove has judiciously re- 
marked, these vomitings, when they have lasted a long time, produce such 
an enfeeblement of the organism that all medical intervention is well nigh 
useless. 

Apostoli has proposed to galvanize the pneumogastric during digestion, in 
order to prevent these vomitings. He requires the patient to take food; then 
immediately afterward he places the positive pole over the pneumogastric 
nerve on the right side, in the region of the neck, while the negative pole is 
held in the hand; then he passes a current of variable intensity, according as 
the nausea is more or less frequent. I have, by this means, employed in my 

1 Vide Charcot, Troubles de la vision chez les hysteriques, Progres Medicale, 1878, p. 
37. Bonnefoy, Des troubles de la vision dans l'hysterie (These de Paris, 1874). Baron, 
Troubles de la vision ches les hysteriques et les hystero-epileptiques (These de Paris, 1877). 
Galezovvski, Progres Med., 1878, p. 39. Dujardin-Beaumetz et Abadie, Hysterical Amau- 
rosis, Amelioration by Metallotherapy and by Magnets; Complete Cure under the Influ- 
ence of Static Electricity (Progres Medical, 1879). The following is a brief resume of this 
most interesting observation: Mile. X., aged sixteen, went to bed, January 21, with head- 
ache; had never before experienced any symptoms of hysteria; the next day, the 22d, she 
awoke totally blind. Examination of the eye by Abadie did not reveal any alteration of 
the fundus of the eye. There was loss of cutaneous sensibility on both sides of the body. 
Three pieces of gold were applied to the left temple, and in half an hour partial vision was 
restored on that side, but on the right side blindness persisted. Acuity of vision in the left 
eye, one-tenth. Magnets were applied, which ameliorated the right eye, and the sight of 
the left eye. February 5, acuity of vision was two-sevenths on the left, and one-fifth on the 
right. Each application of the magnet, or of metal, induced a state of lethargy; static 
electricity was then employed, and this completed the cure, and it has been permanent. 

2 Maladies du Syst. Nerveux, L i. lect. ix. See also Ballet, Two Cases of Nervous 
Vomiting, Treated with Success by Forced Feeding (Prog. Med., June, 17, 1882). Deniau, 
De l'hysterie gastrique et de son traitement (These de Paris, 1883). Huchard, Traite des 
neuroses, Paris, 1883. Fabre (de Marseille), De l'hysterie viscerale, Paris, 1882. 



106 ON THE TREATMENT OF HYSTERIA. 

service, seen digestion performed without rejection of the matters of the stom- 
ach. I shall not enlarge upon this therapeutic measure, which I fully treated 
of when lecturing on diseases of the stomach. 

Such are the considerations which I wished to present respecting the 
treatment of hysteria. The therapeutic indications which I have furnished are 
far from being complete; at the same time I think them sufficient to enable 
you advantageously to combat the principal manifestations of this neurosis. 
But do not forget, gentlemen — and with these words I conclude — the complete 
cure of hysteria is very rare. You will hardly have triumphed over one of the 
many manifestations of this protean malady before others will make their ap- 
pearance, and, notwithstanding all your knowledge, and all your energy, you 
will continually fail in the contest with these nervous troubles, ever renewed, 
and ever rooted in the depraved and insatiable imagination of the hysterical 
patient. 



ON THE TREATMENT OF EPILEPSY. 

Summary. — Treatment of Epilepsy — Curability and Incurability — General Treatment — 
Pathogeny and Etiology — Experimental Epilepsy — Disease of the Spinal Cord, the 
Nerves, and the Brain — Causes — Therapeutics of Symptomatic Epilepsy — Antisyphilitic 
Treatment — Revulsion — Essential Epilepsy — Physiological Pathology — Treatment of 
Essential Epilepsy — Empirical Medication — Galium, Valerian, Hyosciamus, Belladonna, 
Indian Hemp, Nitrate of Silver, Oxide of Zinc, Ammonio-sulphate of Copper, 
Bromide of Potassium — History — Physiological Action of Bromide of Potassium — 
Employment of Bromide of Potassium in Epilepsy — Result of the Treatment — Rules of 
Administration — The Alkaline Bromides — Bromides of the Metals — Doses — Mode of 
Administration — Duration of Treatment — Curare, Cocculus Indicus and Picrotoxine— 
Treatment of the Attack — Hygienic Treatment. 

Gentlemen : I devote this lecture to the treatment of that most formidable 
of the neuroses — epilepsy. 1 When we survey the numerous remedies which 
have been proposed for this disease — remedies often uncertain and inefficacious 
— we easily comprehend the discouragement and despair of many physicians 

1 Epilepsy (haut-mal, morbus sacer, herculeus, falling sickness, St. John's evil, etc.), is 
divided into symptomatic, idiopathic and sympathetic epilepsy. It is known under two 
principal forms, the grand-mal (convulsive form), and the petit-mal (form not convulsive). 
The grand-mal is often ushered in by prodromes lasting several instants or even hours or 
days. The patients are subject to divers troubles, lassitude, choking sensations, palpitations, 
pains in the stomach, cephalalgia, buzzings in the ears, dazzling sensations, perception of 
strong odors, of strange tastes, hallucinations of the sight and hearing. Some persons have 
an irresistible desire to walk, to run, to leap, others present a manifest change of character, 
become gay or sad ; some have cerebral excitation, genital excitation, pollutions. Others 
complain of a sensation of cold, of tickling, or of pain which pursues generally an ascending 
course, starts in the foot or some other remote part, to mount up to the head with greater or 
less rapidity. Whether these phenomena, constituting what has been called the aura epi- 
leptica, exist or not, the patient is taken suddenly in a fit, he utters a cry, loses 
consciousness, and falls as if by lightning, generally in front, no matter where or on what 
object. The face is of cadaveric pallor ; all sensibility is abolished ; the patient is comatose. 
Soon arrives the convulsive period, the face colors rapidly, tonic convulsions immobilize the 
patient, who lies extended on his back, the head thrown behind or inclined to one side, the 
eyeballs hidden under the lids ; the face is convulsed, the teeth are tightly set against each 
other, the limbs contractured, the hands bent back, the thumb adducted, flexed in the palm of 
the hand. Respiration is suspended. This period of tetanism gives place soon to short, 
rapid shocks, then to clonic convulsions, which become more and more rapid and general. 
The limbs, sometimes in supination, sometimes in pronation, flexion or extension, are 
agitated by continual shocks. The face is colored reddish purple, the forehead is wrinkled, 
the eyes roll in their sockets, the eyelids quiver, there is grinding of the teeth, the jaws open 
and shut with such force as sometimes to break the teeth or bite the tongue, wounding it 
severely ; a frothy and bloody saliva escapes from the mouth. Respiration is convulsive, 
unequal, stertorous. The heart beats with force. Sometimes there is an abundant and in- 
voluntary emission of urine or of fecal matters ; some subjects have even seminal polutions. 
After one or two minutes of this stage, the convulsions abate, the patient utters a deep 
sigh, respiration becomes full and strong, and is accompanied with stertor ; the countenance 
becomes pale, is covered with perspiration, and the patient sleeps profoundly. This apo- 

107 



108 ON THE TREATMENT OF EPILEPSY. 

who have pronounced epilepsy incurable ; moreover we see why the ancients 
attributed a divine origin to this affection, for to them the words morbus sacer, 
moi'bus divinus, testified sufficiently that the disease was generally above the 
resources of their art. But this feeling of discouragement ought no longer 
to exist. We have already found in the bromides a remedial agent which 
enables us to cure one half our epileptic patients, and we may be permitted 
to indulge the hope that some day we shall find a remedy still more power- 
ful, which shall give us complete mastery of the disease. For this end we 
shall labor, and with all zeal. 

It may almost be said that every medicine under heaven has one time 

plectiform state lasts more or less long (from several minutes to several hours), and then the 
patient comes to himself, stupid, in a maze, quite unconscious of what has passed. Generally 
he is exhausted and complains of headache. There are even subjects who remain for some 
time hemiplegic and even aphasic. Others, on the contrary, recover almost immediately 
and have full possession of their physical and mental faculties. During the attack the pulse 
and the temperature present certain modifications. The pulse before the attack is rapid, 
cordy, and acquires force as the paroxysm advances. The temperature rises during the at- 
tack to 38 C, 38. 5 C, and even to 40 C. during attacks of great intensity. On the part 
of the eye, during the aura there is observed, according to Brown-Sequard, Kusmaul, and 
Tenner, contraction of the arterioles and anaemia of the retina ; according to others a 
hyperaemia of this membrane and encephalic congestion. Sometimes the attack may pass 
unperceived, when, for instance, it takes place in the night time. The patient relates with 
astonishment that he has wet his bed, that he found himself in the morning lying at the foot 
of the bed, and that he has headache ; in fine that his tongue is bitten and hurts him. 
The onset of the attack of epilepsy has nothing about it that is fixed, either in respect 
to the time of its appearance or its duration. The fits may occur only at long intervals, or 
they may come on very often — several times in the same week, or same day; one may scarcely 
end before another begins, this sort of overlapping constituting what has been called the 
status epilepticus. The attacks have not always the same violence and certain convulsive 
phenomena may be wanting; the convulsions may be slight, and be limited to a general stiffness, 
a partial convulsion, the projection of a limb in front, behind or to the side, an imperious 
desire to rise, to walk, etc.; the patient does not cry out, does not fall, grows very pale, then 
comes to himself serni-conscious and stupid. 

The petit-mal, the non-convulsive form of epilepsy, is characterized by absence of mind, 
vertigo, delirium. The attack comes on without prodromes. The patient is suddenly 
taken while reading, or engaged in conversation, a game of cards, etc. He stops 
suddenly as if stunned, becomes pale, has a fixed look, an aspect of hebetude, makes 
grimaces, then two or three seconds after he resumes his occupation completely unconscious 
of what has passed. Other patients fall suddenly from where they are standing or slip out 
of their chair, and rise up without perceiving their fall. Others in the midst of some occu- 
pation leave their place, go out and come back, without any remembrance of their conduct. 
There are some who during their sudden attack present contractions of certain muscles, pallor 
of the face, but continue mechanically and automatically the work which they had com- 
menced. Other patients are taken with a more or less violent delirium of word and of 
action ; they suddenly ejaculate incoherent words, make strange gestures, gesticulate 
violently or feel an impulse to walk, to run, etc. Under the impulsive and instantaneous 
delirium some commit obscene or criminal acts and cause themselves to be arrested for 
outrages against decency, for theft, homicide or arson. Then when after a period of greater 
or less length these unhappy beings come to themselves they have not the least recollection 
of their acts. These attacks last a few minutes, several hours or even several days ; they 
may have temporary remissions or exacerbations. 



ON THE TREATMENT OF EPILEPSY. 109 

or another been prescribed for epilepsy. Do not, then, expect from me an 
enumeration of this long list of medicaments ; I shall merely touch upon a 
few of them to lay particular stress upon such as experience has proved effica- 
cious. To give some system to my exposition, I shall divide the treatment 
of epilepsy into two parts: first, general treatment ; second, treatment of the 
attack. In order to grasp the principles of the general treatment it is neces- 
sary to enter somewhat into details respecting the pathogeny of this affection. 1 
Sometimes epilepsy is manifestly dependent on a lesion of the nervous system, 
it is then symptomatic ; sometimes no lesion is apparent, and we call the 
epilepsy essential. 

As for symptomatic epilepsy, experimental physiology and clinical obser- 
vation have given us certain proofs of the influence of lesions of the nervous 
system on the development of this neurosis. Brown-Sequard by his curious 
experiments on guinea-pigs has shown us that epilepsy may be produced by 
section or ablation of the sciatic nerves, and what is stranger and still more 
inexplicable, that this experimental epilepsy affects not only the animal so muti- 
lated, but also its offspring, so that epileptic guinea-pigs, in consequence of 
lesions of the sciatic nerves, ever afterward have epileptic progeny. 

1 The causes of epilepsy, which are multiple, may be divided into predisposing and 
exciting. It may be symptomatic, idiopathic, and sympathetic. The disease appears to 
affect women oftener than men, and preferably individuals that are delicate, lymphatic and 
nervous. It manifests itself towards the age of puberty or adolescence; it is rare that it ap- 
pears after twenty-five or thirty, and in these cases, if observed in an individual previously 
healthy there is reason to believe it to be of syphilitic origin. Epilepsy may be hereditary, 
entailed as a legacy to the children by the father or the mother, or by the grand-parents, it 
the neurosis has skipped a generation, as sometimes happens. The parents may not be 
epileptic themselves, but only sufferers from neuroses, or chronic alcoholism, which is 
capable of giving origin to the disease. Epilepsy whose primary cause seems to consist 
in an abnormal excitation of the medulla oblongata, may be symptomatic of lesions of the 
nervous centres or of their membranes, of lesions of the cervical cord determined by com- 
pression, according to Charcot. The experiments of Brown-Sequard have shown, moreover, 
that you may provoke epileptic convulsions in an animal by making section of a part of the 
cord. According to Prof. Lasegue, epilepsy depends generally on a malformation of the 
cranium, or asymetry of the face. The disease is also often observed to follow traumatism 
of the cranium, depressed fracture of the bones, and compression of the brain. In these 
cases the application of the trepan sometimes effects a cure, if there has taken place no altera- 
tion of the encephalon. 

In connection with true epilepsy it is proper to allude to the epileptiform con- 
vulsions which supervene in certain paludal fevers, in poisoning by alcohol, lead 
and mercury ; in disease of the kidneys, Bright's disease, uraemia, in cases of cerebral 
tumors (cancer), in general paralysis. These cases differ from true epilepsy in this respect 
that very often there is neither the initial cry nor the characteristic pallor of the countenance 
nor the same comatose condition. 

Syphilis is a frequent cause of epilepsy ; the crises are at first only occasional, 
then they become frequent; they are often complicated with partial paralysis which may affect 
the monophlegic or hemiplegic form. Strong mental emotions, such as fright, anger, joy, 
disappointment, nervous exhaustion brought on by mental or physical excesses, severe pain, 
neuralgia, extreme heat or cold, are, according to some authors, so many causes of epilepsy. 
Wounding of sensory nerves (pricking, contusion, lacerating by a splinter of bone), com- 
pression of these nerves by a tumor in the neighborhood, a neuroma ; the presence of the 



110 ON THE TREATMENT OF EPILEPSY. 

The same symptoms are produced in certain lesions of the spinal marrow 
or cerebrum. Westphal rendered guinea-pigs epileptic by blows on their heads. 
Hitzig, Eulenburg, and Landois by irritating the motor cortical centers of 
animals by mechanical and chemical agents, and by electricity, brought on 
attacks of epilepsy. Points have been localized in the cerebro-spinal axis whose 
excitation produces epilepsy, and Albertoni and Koloman-Balogh have given 
precise directions in this regard. Roberts Bartholow has gone even farther, and 
in a patient, the surface of whose brain was denuded to some extent, he has 
produced epileptiform convulsions by applying electricity to the exposed cortica, 
substance, (a) Clinical observation strikingly confirms these experimental facts, 
and the annals of medicine contain a vast number of cases where wounds and 
irritations of nerves have determined epilepsy, and where it has sufficed to re- 
move the vicious cicatrix, or the foreign body embedded in the tissues, in 
order to obtain a permanent cure. In other instances the epilepsy has resulted 
from injuries or compressions of the cerebral substance, by spiculae of bone, by 
abscess, by tumors ; the removal of the bony splinters or the disappearance of 
the tumors has brought about complete cure. 

It is in cases of this kind that the application of the trepan in the treat- 
ment of symptomatic epilepsy gives good results. Extolled by the ancients in 
an empirical fashion, the trepan has of late years found its legitimate place, a 
place, in fact, of such importance that we have seen in America an eminent 
surgeon perform this operation for the cure of epilepsy twenty-three times in 
five years, and obtain seven complete recoveries. Echeverria, in his interesting 
statistics, gives the results of one hundred and forty-five cases, ninety-three of 
which were permanently cured by the trepan. 

In the same group we place anti-syphilitic medication, for oftentimes the 

larvae of insects in the frontal sinuses may determine the development of the neurosis, 
(sympathetic or reflex epilepsy). It is the same with alterations or strange affections of the 
different viscera, of the stomach, of the intestine, the liver, the kidneys, the genito-urinary 
organs. Gastrointestinal epilepsies are equally admitted. 

Some authorities have related cases of attacks occurring especially in plethoric indi- 
viduals as a sequel of indigestion, where improper articles of food have been indulged in or 
where there has been departure from the ordinary habits of diet. The presence of worms 
in the intestine and obstinate constipation, have often induced convulsions in persons predis- 
posed. Moreover, in females slight lesions of the neck of the womb or displacements of that 
organ are sometimes sufficient to determine epilepsy. Menstruation has a manifest influence 
on the development and march of epilepsy. It is, in fact, generally at the period of 
the establishment of the menses or at the epoch of the menopause that the disease first 
appears. In fine there is a multitude of other causes which are operative in persons pre- 
disposed ; the perception of certain odors, the sight of certain objects, sometimes the dis- 
appearance of certain rashes, etc. 






(a) Brown-Sequard : Researches on Epilepsy, its Artificial Production in Animals, 
and its Etiology, Nature, and Treatment in Man, Boston, 1857; Pietro Albertoni —Influence 
of the Cerebrum in the Production of Epilepsy, Milan, 1876 ; Roberts Bartholow : Experi- 
mental Investigation into the Functions of the Human Brain, American Journal Medical 
Society, April, 1874 ; Westphal: Berliner klinische Wochenschrift, Nos. 24 and 39, 1871 ; 
Vulpian: Epilepsy in the Guinea-pig after section of the Sciatic Nerve. 



ON THE TREATMENT OF EPILEPSY. Ill 

relation which exists between this neurosis and syphilis is explained by the 
presence of gummata, or bony tumors compressing the brain and spine, and it 
is quite clear, as Fournier and Dreschfeld have shown, that in cases of this sort 
the specific is the proper treatment for the neurosis. In this same category we 
must place epileptiform convulsions due to the presence of worms in the intes- 
tines, and which disappear with the expulsion of the offending cause. In this 
group, too, we must place those cases of epilepsy connected with troubles of 
the genital functions, for the relief of which Marshall Hall proposed castration. 

It was formerly maintained that epilepsy results from a chronic inflamma- 
tion of the brain and spinal cord; a variety of epilepsy was even described 
under the name of plethoric epilepsy. Morgagni, Fothergill, and others 
defended this doctrine of the constant inflammatory origin of epilepsy, hence 
their antiphlogistic treatment, which consisted in blood-letting and the most 
powerful derivatives, such as cauteries, blisters, and setons. This kind of 
treatment is now a thing of the past; it gave no certain results of any value, 
and was based on a hypothesis which the recent anatomo-pathological researches 
on essential epilepsy have not confirmed. 

We know that since the labors of Schroeder-Van der Kolk and Echeverria, 1 
the post-mortem disclosures in deaths from epilepsy have generally been alter- 
ations of the medulla oblongata, characterized by an intercellular albuminous 
exudation and capillary ectases. It may, however, be reasonably affirmed that 
these lesions are the consequence rather than the cause of attacks of epilepsy. 2 

1 These are the statistics of Echeverria : 

Recoveries, 93 

Ameliorations, . . . . . 18 

No change at all, 5 

Aggravation, ..... 1 

Deaths, . . . . ' . . .28 

Mason Warren, in 10 cases of trephining, reports 3 cures, 2 ameliorations, and 5 
deaths, (a) 

2 The necroscopic examination of epilepsy very often gives results quite negative, with 
nothing to explain the phenomena during life; at other times, however, there are found 
alterations of recent date, or of long standing, to which the disease may be attributed, 
Leaving one side lesions of the members or of certain viscera which provoke sympathetic or 
reflex epilepsy (wounds of the sensory nerves, affections of the stomach, of the intestines, 
of the genital organs, etc.), we will recall the principal alterations described by writers. On 
the part of the cranium, thickening, deformity, whether by depressed fracture, the presence 
of foreign bodies, or of bony tumors; vices of conformation, cranial asymetry, an arrested 
development of the face; in fine, fronto-facial asymetry. According to Lasegue, who has 
devoted much study to this question, the asymetry which is observed in epileptics seems to 
respond to two types: either the face has undergone movements of rotation in a direction 
opposite the frontal region, or else it is drawn in the same direction. In the first case, to 
the right frontal prominence corresponds a left molar prominence; in the other case, the 
prominences are on the same side. The first form is the most common. The lesions of 



(<z) Trephining for epilepsy (Boston Med. and Surg. Journal, 1872— Echeverria on trephining in hysteria 
from traumatism of the cranium (Arch, de Med. de Paris, 1878, t. 11, p. 529.652), Mason Warren, Boston Med. 
and Surg. Journal, 1867). 



112 ON THE TREATMENT OF EPILEPSY. 

Nevertheless, the rachidian bulb has a predominant part in epilepsy, and it is 
by modifications of its functions that we best explain the convulsive paroxysms. 

The first phase of the attack, that which corresponds to the initial outcry, 
to the loss of consciousness, and to the tetanic contraction of all the muscles of 
the economy, would seem to result from an excitation of the medulla oblongata, 
sufficient to cause sudden anaemia of the cerebrum and of the bulb itself. 
Next comes the asphyxia, consequence of this tetanic state, and the passive 
congestion of the cerebro-spinal axis which it produces. Next in order is a 
period of reaction, in which the accumulation of venous blood in the encephalon 
and spinal cord determines clonic convulsions everywhere, the respiration is 
stertorous, the face is blue, the attack terminates with exhaustion of the nervous 
centres implicated. In these phenomena the medulla oblongata is principally 
concerned, and the therapeutic indication is plain; every medicament which 
tends to diminish the' excitability of the medulla oblongata, and the cerebral 
anaemia which results from it, is applicable to the treatment of epilepsy. But 
before beginning the consideration of the physiological treatment of epilepsy, 
I will say a few words about the empirical treatment. 

Certain simple herbs have enjoyed a great repute in the treatment of epi- 
lepsy, and the common people have accorded heroic curative virtues to a num- 
ber of indigenous plants which deserve a brief mention here, as their anti-epileptic 
properties have been endorsed by certain physicians. 

Galium verum and galium mollugo (" white cheese rennet," "yellow ladies' 
bedstraw," are the familiar names) are reputed as having quite special virtues 
in the treatment of epilepsy, and we are frequently referred to the observations 
of Jourdan and Miergues, fils. I believe that even now certain religious com- 



the encephalon are: for the meninges, a thickening of the dura mater, ossification of the 
falx cerebri, of the tentorium cerebelli, fungous growths, abscesses, adhesions of the thick- 
ened pia mater to the encephalon, tumors, cysts of the choroid plexus, the lesions of meningo 
encephalitis. The brain substance presents: congestion or pallor, softening or induration 
of the white and gray matter, atrophy or incomplete development of the cerebral lobes, 
tumors of divers natures, tubercles, cancers, cysts, hypertrophy of the pituitary gland, 
asymetry or inequality of weight of the cerebral hemispheres, lessened weight of the cere- 
bellum, sclerous induration and atrophy of one or both of the cornua Ammonis, or softening 
of these cornua. These lesions, regarded immediately after death, may be considered as 
being of relatively ancient date. Among the recent lesions, or those seeming to be such, 
and judged to be consecutive to the attacks themselves, are found, if death has occurred 
during or immediately after an attack, certain phenomena of asphyxia, ecchymoses under 
the scalp, sub-pleural ecchymoses, congestion of the lungs, of the liver, of the spleen, of the 
kidneys, injection, with ecchymotic patches of the pia mater, etc. The cerebral hyperaemia 
so frequent is seated preferably at the level of the medulla oblongata, in the gray substance 
of the pons, and this hyperaemia entails divers changes of texture (ramollissement, or in- 
duration, hypertrophy, etc.). 

The congestion, with enormous vascular dilatation, and the ramollissement are often 
found at the point of origin of nerves which have been concerned in convulsions (the hypo- 
glossal, pneumogastric); likewise there has been observed a pigmentation of the ganglionic 
cells of the cervical sympathetic. The works of Luys and of Voisin(Arch. de Med., Dec. 1869) 
have shown that lesions may be met, not only in the medulla oblongata, but also in the 
cortical substance of the cerebrum in the cerebellum and in the cerebellar peduncles. 






ON THE TREATMENT OF EPILEPSY. 113 

munities in France treat this disease with the expressed juice or an infusion of 
this plant. 

Valerian is also an ingredient of a great many anti-epileptic preparations, 
and its employment in this disease is supported by a respectable number of 
eminent names. I will pass rapidly by hyoscyamus, vaunted by Storck and 
Hufeland; daffodill, employed with success by Dufrenois, Vieillchese, Delon- 
champs; bitter orange leaves, counselled by Larcher; peony, extolled by 
Portal, to devote a moment's consideration to belladonna, which, before the in- 
troduction into therapeutics of the bromides, was one of the medicaments the 
most depended on in the treatment of epilepsy, supported, as it was, by the 
authority and experience of Trousseau. Belladonna is given in the form of 
pills, each containing one-sixth of a grain of the powder and one-sixth of a 
grain of the extract; dose, one pill morning and evening the first month, and 
every succeeding month you increase the dose by one pill a day, till you arrive 
at the enormous dose of twenty pills night and morning. 

All these medicaments, belladonna included, are to-day completely aban- 
doned; they have had to yield their place to more active and more certain 
medicines, and I have only mentioned them here because they belong to the 
history of the therapeutics of epilepsy. By the side of these vegetable sub- 
stances we must place the mineral remedies which have been prescribed for the 
falling sickness; these are especially certain metals, such as silver, copper, and 



1 Oxide of zinc (flowers of zinc, or philosophers' wool) is a white substance, tasteless, 
inodorous, insoluble in water, and is obtained by roasting metallic zinc in a crucible in con- 
tact with air. Oxide of zinc is given internally in the form of pills, or of powder, in the 
dose of twenty centigrammes to one gramme (from 3 to 15 grains). Herpin, of Geneva, 
employs oxide of zinc in the following way: 

1. For adults during the first week, 3 grammes (45 grains), rubbed up with 4 grammes, 
(1 dram), of sugar, and divided into 20 doses; 3 doses a day, one hour after each meal. 
Increase by 1 gram (15 grains) a week till the weekly quantity of 15 grammes (225 grains) is 
reached; this to be continued for three months. 

2. From 10 to 15 years of age, weekly quantity of 1 gramme (15 grains); increase by 1 
gramme a week. 

3. From 1 to 10 years, a weekly initial quantity of % a gramme (j}4 grains); during the 
second week the dose is increased to 1 gramme; after that, a weekly increase of 1 gramme. 

4. From the period of birth to 1 year, weekly initial dose of 25 centigrammes; in- 
crease by 25 centigrammes a week till y/ 2 grammes is attained, which is the maximum 
weekly dose. 

Herpin, somewhat more recently, has substituted lactate of zinc for the oxide; he gives 
this salt in the weekly initial quantity of 3 grammes to adults and 1 to 2 grammes to children, 
according to their age. Valerianate of zinc has also been recommended as an antispas- 
modic. Devay, of Lyons, Cerulli, of Parme, and Martin Solon have published cases of 
cure from neuralgia and spasmodic affections by the use of pills of valerianate of zinc, con- 
taining 5 centigrammes (1 grain), and giving 2 to 4 of these pills a day. 

More recently, Luton has recommended for rheumatic pains the cyanide of zinc, and 
this is his formula: 

]$ Cyanide of zinc 20 

Aquae lauro cerasi 25.00 

Mucilage 100.00 



114 ON THE TREATMENT OF EPILEPSY. 

What physiological action can these metallic substances have in the treat- 
ment of epilepsy? We cannot say; possibly we must invoke, in explanation, 
the strange phenomena of metallotherapy observed in accordance with Burq's 
method. However this may be, silver is administered in the form of pills of 
the nitrate, and in doses sufficiently large and sufficiently prolonged to produce 
discoloration of the tissues. They tell a story of an aide-de-camp of King 
Louis Philippe, who had been cured of his epilepsy by this treatment, but 
whose skin was changed to a deep blue. I myself saw, twenty years ago, a 
man transformed into a negro (blue man, they called him) by the internal usage 
of nitrate of silver, but who, notwithstanding this kind of poisoning, was not 
cured of his disease. 

Copper is administered in the form of ammonio-sulphate of copper, and is 
given in the dose of ten centigrammes a day in capsules. Zinc is given in the 
form of oxide; Herpin is the most zealous advocate of treatment by this 
remedy. Out of thirty-six patients treated by oxide of zinc, he obtained 
twenty-eight cures; the dose given was ten centigrammes three times a day, 
gradually increased till six grammes were taken in the twenty-four hours. 
Like the vegetable treatment above described, the metallic treatment of epilepsy 
has gone out of vogue, and to-day it is to the bromides that everyone has 
recourse. 

When Balard, 2 in 1826, discovered bromine, and the striking resemblances 

Mix and shake. 

Dose. — One tablespoonful every hour, (a) 

2 It was in 1826 that Ballard discovered bromine. The first application which was 
made of this substance, and of its combination with potassa, under the name of hydro- 
bromuret of potash, was directed against scrofula and goitre. Two years after the discovery 
of Ballard, in 1828, appeared a work by Pourche, Fellow of the Faculty of Montpelier, on 
the therapeutic employ of bromine. Ten years later, in 1838, bromine and bromide were 
again made the subject of experimentation, this time at the Pitie in the service of Andral, 
and Fournet gives us an account of these trials. Then from 1840 to 1850, Ricord, at the 
hospital du Midi, endeavored to substitute bromide of potassium for the iodide. The two 
internes of this physician, Rames and Huette, studied the physiological and therapeutic 
effects of bromide of potassium. The first defended his thesis the 25th of April, 1850, and 
the second the 8th of May the same year. Rames, in his work, shows that bromide of 
potassium, in large doses, produces anaesthesia ; he experimented on animals with this 
medicine, and compares the general action of the bromide with the symptoms which charac- 
terize the incomplete general paralysis of the insane. He mentions the loss of the sensibility 
of the pharynx, which makes it effectual against nausea, and also calls attention to the 
depression of the genital functions. The thesis of Huette is much more complete. 
He points out all the symptoms of bromism, which he describes with great care, and 
shows the influence of bromide of potassium in syphilis. Locock, in 185 1, was the first to 
apply the bromide of potassium to the treatment of epilepsy, and out of 15 cases he had 14 
cures. Radcliffe repeated these experiments, and affirmed that the name of Sir Charles 
Locock deserved to be perpetuated in the grateful remembrance of all epileptics. Locock 
based his experiments on the results obtained several years before (1 840-1 842) by a German 



(a) Herpin, of Geneva, on the Prognosis and Treatment of Epilepsy, Paris, 1852. Devay on Valerianate 
of Zinc (Gas. Med. de Paris, 1854). Martin Solon on Valerianate of Zinc in Neuralgias (Bull, de Ther., t. 
XXVII, p. 468). Luton on Cyanide of Zinc (Bull, de Ther., 1877. t. XCII, p. 97- 



ON THE TREATMENT OF EPILEPSY. 



115 



between this substance and iodine were pointed out, it was proposed to substi- 
tute the first medicament for the second, and it was in the treatment of syphilitic 
affections more especially that the substitution was made. From 1840 to 1850, 
in the Hopital du Midi, the physicians attached to this hospital, and in particu- 
lar Ricord, employed bromide of potassium in the place of iodide of potassium. 
The first labors recording the results of this treatment, and showing the physio- 
logical and therapeutical properties of the bromide, were made by two internes 
of the hospital— Rames, of Aurillac, and Huette, of Montargis. The thesis of 
Rames appeared April 25, 1850, and that of Huette several weeks after. Six 
years ago (in 1878) George Huette, in an excellent monograph on bromide of 
potassium, showed us the progress made in the usage of bromide of potassium 
since the first experimental and clinical studies of his father in 1850. Those 
early investigations, while clearly setting forth the physiological, therapeutical, 
and even toxic effects of the bromide, made no mention of any application of 
the drug to the treatment of the neuroses, and in particular to epilepsy. 

The year following Locock, taking up a discovery, made several years be- 

named Otto Graf, who had experimented on himself with bromide of potassium, and had 
remarked that 60 centigrammes of this salt (or about 10 grains), taken 3 times a day for a 
fortnight, had caused temporary sexual impotence; this is what led Locock to employ bro- 
mide in hysteria, in hystero-epilepsy, then in epilepsy. Williams, at the insane asylum at 
Northampton, experimented on, 37 epileptics, 19 men and 18 women. The bromide was 
given for 5 months; the 19 men who had had 1,012 attacks in 5 months, had during the time 
of treatment only 706; and in the case of the females, the number of fits fell from 1,127 to 
970. The same year, in 1864, Robert Macdonald experimented with this medicament in 
epilepsy, and obtained the same results as Locock. Blake, in 1864, employed the same 
medicament in a case of hystero-epilepsy. Bazin and Besnier published, in 1865, a case of 
cure of epilepsy. Then appeared, in 1866, in the Bulletin de Therapeutique, the much 
more complete memoir of Dr. Voisin, which was based on 24 observations of epileptic patients. 
From this period this kind of treatment became general, and special treatises, giving reports 
of successes obtained with this salt in epilepsy, have abounded in this and other countries, 
and their very titles are too numerous to mention here. 

To judge of the constantly increasing use of this salt in the hospitals, I need only 
refer to the following statistics given by Lasegue and Regnauld, which indicate the consump- 
tion of bromide at the Pharmacie Centrale of the hospitals from 1855 to the year 1875: 



1855 3.200 K. 

1856 7.100 " 

1857 4-820 " 

1858 2.000 " 

1859 2.517 " 

i860 2.360 " 

1861 2995 " 

1862 5.782 " 

1863 7.601 " 

1864 22.300 " 

1865 73-530 " 



1866 133.300 K. 

1867 13^-643 " 

1868 211.650 " 

1869 406.313 " 

1870 389.900 " 

1871 319.690 " 

1872 529740 " 

1873 596.620 " 

1874 74I-358 " 

1875 730.910 " 



From the table it appears that in twenty years the consumption of bromide of potas- 
sium which was 3^ kilogrammes, or about 7 pounds, in 1855, had increased in 1875 to 
735.910 k., or the enormous quantity of about 1,500 pounds. This ought to be enough to 



116 ON THE TREATMENT OF EPILEPSY. 

fore by a German, Otto Graf, who had noted in himself a marked depressant 
action following the use of large doses of bromide of potassium, and in par- 
ticular, sedation of the genital functions, for the first time applied these data to 
the treatment of hystero-epilepsy and of epilepsy, and out of fifteen cases treated 
by the bromide recorded fourteen cures. The name of Locock ought to be im- 
mortalized in the history of medicine ; he deserves the gratitude of the whole 
human race, because through his happy discovery of the use of bromide of 
potassium in epilepsy, he has enabled us to cure one half our cases. 

After the labors of Locock, came those of Radcliffe, Brown-Sequard, and 
especially of Williams, showing that one could in five months diminish in a 
marked manner the number of attacks in a given number of epileptics. From 
this moment, bromide of potassium has been almost exclusively employed in 
the treatment of epilepsy, and the memoirs of Voisin, Legrand du Saulle, Falret 
of Lasegue, etc., in our country show the beneficial results which may be 
expected. 

Consult these documents, examine the statistics furnished by these physi- 
cians, and you will see that in more than half the cases we may favorably 
modify the condition of epileptic patients. I say modify, and not cure, for I 
range myself on the side of those who contend that a complete and permanent 
cure of real epilepsy by the bromide treatment is rare, without being, never- 
theless exceptional. But it is possible, in one case out of every two, to cause 
the attacks to disappear, on condition, always, of "prolonging indefinitely the 
medication ; and this is no small blessing. The bromide is, then (in the words 
of Legrand du Saulle), the muzzle of epilepsy, rather than a definite curative 
medicament. 3 

negative the assertion of some writers, and particularly Drouet, that the bromide medication 
is destined to have only a fleeting popularity, to be hereafter abandoned like all other kinds 
of treatment that preceded it. {a) 

3 Legrand du Saulle has given complete statistics pertaining to 272 epileptics treated 
both in the hospital at Bicetre and in his private practice by bromide. His facts are grouped 
as follows: 

Clinical observations of the first series. — Absolute suspension of fits ; no vertigo or 
petit-mal. 

A, during five years, 2. 

B, during four years, 17. 

C, during three years, 11. 

D, during two years, 8. 



(a) Otto Graf, on the Internal Efficacy of Bromide of Potassium, as shown by Experiments. Leipzig, 
1840. Locock, The Lancet, 1857, vol. I, p. 528. Pourche\ Observations on the Employ of Bromide and Hydro- 
bromuret of Potash in Scrofula and Goitre. (Ephem. Med. de Montpeleier, t. VIII, p. 45 to 54, 1828.) 
Fournet, on the Therapeutic Use of Bromine in Chronic Arthritis, (Bull, de Ther., t. XIV, p. 87.) Rames, 
Studies on the Anaesthetic and Therapeutic Effects of Bromide of Potassium (These de Paris, 1850). Williams, 
on the Action of Bromide of Potassium, 1864. MacDonnell, Observations in Support of the Treatment of 
Certain Forms of Epilepsy by Bromide of Potassium (Dublin Quarterly Journal of Med. Science, 1855), 
Blache, Hystero Epilepsy Treated by Bromide of Potassium (Bull, de Ther., t. LXXVII, 1864). Bazin et 
Besnier, Epilepsy Cured by Bromide of Potassium (Gaz. des Hop., 1865). Voisin, Clinical Researches on 
Bromide of Potassium and its Employ on the Treatment of Epilepsy (Bull de Ther., t. LXXII, 1866). Drouet, 
Documents to serve as a History of Bromide of Potassium (Annal. Med. Psych., Sept., 1873). Lasegue et 
Regnault, Therapeutics Judged by Statistics (Arch. Med., 1877). 



ON THE TREATMENT OF EPILEPSY. 117 

How ought you to institute the bromide treatment ? Which bromide 
ought you to choose ? What are the inconveniences of this medicament? How 
long ought you to continue the treatment ? These are questions which I must 
now answer. 

But I must first of all say something about the physiological action of the 
bromides. Already, apropos of diseases of the heart, I referred to the action of 
bromide of potassium on the economy, and I need not repeat what I then said. 
All physiologists are to-day agreed in conceding to the bromide a sedative 
action on the cerebro-spinal axis, and in particular on the medulla oblongata. 
If any point is under dispute, it is not whether this substance has an elective 
action op the rachidian bulb, but whether this action is primitive or secondary. 
Some, as Germain See and Binz, maintain that the bromide acts first on the 
heart, and consecutively, by producing anaemia, on the bulb ; others, on the 
contrary, affirm that the heart is affected secondarily; that it is only influenced 
because the medulla oblongata has been first depressed. This depressant 
action on the excito-motor power of the mesocephalon is of marvellous applic- 
ability to epilepsy, since we have just seen that in this neurosis it is excitation 

E, during eighteen months, 21. 
Total, 49. 

Clinical observations of the second series. — Suspension equally absolute of epileptic 
attacks : 

A, during fifteen months, n. 

B, during one year, 8. 

C, during eight months, 21. 
Total, 41. 

Clinical observations of the third series. — Considerable amelioration; no epileptic fit 
during the time which oscillates between three and seven months, 23. 

Clinical observations of the fourth series. — Relative amelioration (remission of one to 
three months duration, disappearance of the major attacks, but persistence of occasional 
vertiginous attacks ; partial return of memory ; appreciable amendment in the mental con- 
dition ; complete cessation of the nocturnal incontinence of urine, of tongue-biting, and of 
headache, 30. 

Clinical observations of the fifth series. — Failures, 129. 

In his treatise on the action of the bromide of potassium, Voisin has gathered 96 
observations of epileptics treated by bromide: 

Complete cure, lasting for several years 22 

Persistence of the aura, absences and vertigo 42 

Failures 32 

Total 96 

Hughes-Bennett has furnished some statistics on the results of treatment by bromide; 
these statistics concern 117 cases. Twelve per-cent of the patients had their fits completely 
suppressed ; in 83-per-cent there was notable diminution, and in 5-per-cent only was there 
utter failure, (a) 



{a) Legrand du Saulle, on the Prognosis and Treatment of Epilepsy, Second Ed., 1873, p. 15. Otto, on 
the Treatment of Epilepsy by Bromide Potassium (Arch, of Psychiatrie, und Nerven-Krank., Vol. V, fasc. 1, 
p, 24. Auguste Voisin, Bromide of Potassium in Nervous Diseases (Mem. del 'Acad, de Med., t. XXXI, 
1875). H. Bennett, a Statistical Inquiry into the Action of the Bromides in Epilepsy (Edinb. Med. Journ., p. 
706, Feb., 1881). 



118 ON THE TREATMENT OF EPILEPSY. 

of the rachidian bulb which determines the congeries of symptoms which 
characterize epilepsy, and this physiological action explains why suspension of 
the convulsive attacks follows the use of the bromide. 

In the bromides what is the active principle ? Is it the bromine, or is it the 
base? This is a question which has been much studied, and which seems to us 
to-day to be solved. The bromine plays a considerable part in this depression 
of the bulbar functions, but the base does not by any means remain inactive 
or inert. 1 And this it is which explains the difference of action of the different 
bromides. We know, especially since the labors of Laborde, that the salts of 
potash have a much more marked depressant action than the salts of soda, and 
that they have a toxic effect on the heart in particular. Already, when treating 
of purgatives, I have showed you the difference which exists between the salts of 
potash and of soda; there is the same difference between chlorate of potash 
and chlorate of soda, as Laborde has shown; also between bromide of potas- 
sium and bromide of sodium, the first being more active than the second, 
while on the other hand the sodium salt is better tolerated than the potassium 
salt. 

I have made many trials of bromide of sodium in epilepsy, and notwith- 
standing the considerable doses exhibited, ioto 12 grammes (150 to 180 grains) 

1 Krosz in his experiments made on animals and on man, endeavored to show that in 
the action of bromide of potassium it is to potassium, to the base, that is due the paralysis 
of the heart muscle, the slowing of the respiration, the lowering of the temperature, the 
paralysis of the nerves and muscles. It is to the bromine on the contrary, that are to be at- 
tributed the insensibility of the pharynx, and the central paralysis of the nervous strands 
which connect the sensory with the motor ganglia. Sidney Ringer and Wm. Murrell have 
made comparative experiments with bromide of potassium and chloride of potassium, and 
they arrive at conclusions almost identical with those of Krosz. According to them, the 
action on the sensory nerves depends principally on the base, and not on the bromine. 
Nevertheless the paralyzing action cannot be due to the potassium alone, for the loss of sen- 
sibility lasts twice as long with bromide of potassium as with the chloride. Steinauer, of 
Berlin, has also experimented on animals with the bromine compounds. 

Jules Cheron and Raoul Fouques, physicians at St. Lazarre, have experimented with 
the three bromides (bromides of potassium, sodium, and ammonium), and these are their 
conclusions: These salts act by their bromine as moderators of the reflex centers. Bromide 
of potassium to its sedative action on the nerve centers joins a depressant action on the 
muscular system; it is a neuro-muscular medicament. Bromide of sodium acts like bromide 
of potassium on the nerve centres, but it does not act on the muscular system; it is simply a 
moderator of the reflexes. The bromide of ammonium is a moderator of the reflexes by its 
bromine, like the two preceding, and by its ammonium, it is a diffusible excitant. There- 
fore when you wish to act on the reflex power and on the muscular system, you will choose 
the bromide of potasium. When you desires to act only on the reflex centres, the sodium 
salt is indicated. And lastly, when you wish to act on the nervous centres and induce a 
slowing of the circulation, a lowering of arterial tension without muscular depression, 
the bromide of ammonium should be chosen, (a) 



(a) Krosz, on the Physiological Action of Bromide of Potassium (Arch, fur Experiment. Pathol, und 
Phar., p. 1, 1876. Sydney Ringer and Wm. Murrell, Concerning the Action of Chloride of Potassium on the 
Nervous System of Frogs (Jour, of Anat. and Phy., t. XII, October, 1877). Steinauer, Untersuchungen iibei 
die Physiologische Wirkung der Brompraparate (Arch. f. Path. Anat. Med. Physiol., LIX, lirr. 1). Jules 
Cheron and Raoul Fouques, on the Comparative Action of Bromide of Sodium, Bromide of Potassium, and 
Bromide of Ammonium (Jour, de Ther., 25, 1881, p. 617). 



ON THE TREATMENT OF EPILEPSY. 119 

a day, I have never succeeded in arresting attacks either of petit-mal or grand- 
mal by this salt. I have, therefore, been astonished to see in Hammond's re- 
markable work on "Nervous Diseases," that this eminent neuropathologist 
gives the preference to bromide of sodium in epilepsy. 1 

By the side of bromide of potassium we must place bromide of ammon- 
ium, which has a still more powerful action than the first; then bromide of cal- 
cium, with which I have never experimented, but which is much employed in 
America, and especially by Hammond. 2 The latter, while giving the prefer- 
ence to bromide of sodium, considers bromide of calcium superior to the 
potassium salt; one gramme producing a sleep which is calm and refreshing. 
His vehicle of administration of the calcium preparation is syrup of the lacto- 
phosphate of lime. 

I have enumerated the alkaline bromides, of which the most employed is 
assuredly bromide of potassium. These bromides are often associated in pre- 
scription, a mode of administration called the mixed bromides. 

There are other bromide compounds which are sometimes given, as the 
bromide of zinc and bromide of camphor. Theoretically, the zinc bromide 
should be a good preparation, since zinc oxide possesses anti-epileptic proper- 
ties, as we have before seen. Bromide of zinc is used in England and 
America in the form of a syrup. Hammond speaks highly of this salt in 
epilepsy. 

Introduced into therapeutics by Deneffe, of Brussels, and investigated 
chemically by Clin, therapeutically by Bourneville, bromide of camphor 3 has 
been employed in the treatment of hysteria and epilepsy, and although favor- 
able results have been obtained at the Saltpetriere, yet this preparation has not 

1 Hammond on Nervous Diseases, p. 806. Paris, 1879. ( a ) 

2 W. A. Hammond : The Therapeutic Usage of Calcium Bromide, New York Med. 
Jour., 1872, and Bulletin gen. de Therapeutique, 1872; also, Hammond on Diseases of the 
Nervous System, p. 886. Hammond's formula for bromide of zinc is as follows: 

I£ Bromide zinc grammes iij. (or gr. xlv). 

Syrup simplicis. grammes xxx (1 fl. oz). 

M. Dose. — Ten drops three times a day. The quantity to be gradually increased till 
thirty drops or more are given at a time. Each dose should be well diluted with water be- 
fore taking, as it is apt to offend the stomach. 

3 Bromide of camphor has been obtained in the form of beautiful crystals by Olin and 
Silva. It has been studied from a physiological and therapeutical point of view by Deneffe, 
of Brussels, and Bourneville. It diminishes the pulsations of the heart, and the number of 
respirations; it also lowers the temperature. It has moderate hypnotic properties. Deneffe 
has treated delirium tremens with it, and Bourneville has employed it in chorea and epi- 



(a) Dr. J. Leonard Corning, of New York, in the Medical Record, Sept. 29, 1883, takes the author to task 
for this denunciation of bromide of sodium in the treatment of epilepsy, and gives as the result of his own 
experience his preference for the sodium salt. He says : "If there is any one fact more thoroughly estab- 
lished than another, it is the superiority of bromide of sodium, and for this reason: that the prejudicial effects 
which are so conspicuous a concomitant of the other bromide preparations are, in great part, absent in the 
sodium salt." Dr. J. W. Morton gives testimony to the same effect. " It is," he says, " a matter of clinical 
experience that larger doses of bromide of sodium may be tolerated for months without evidences of the 
bromide rash, and without failure of health." 



120 ON THE TREATMENT OF EPILEPSY. 

come into general use. Thus far the bromide of potassium remains the medi- 
cament the most active and most employed in the treatment of epilepsy. 

How shall bromide of potassium be administered? Although it has been 
attempted to introduce this salt by the hypodermic method and by enema, these 
tentatives have been promptly abandoned, and for the reason, as I told you 
when treating of diphtheria, that bromide of potassium has an irritant and 
even caustic action. We are then restricted to the alimentary canal as the only 
practical way of introduction, and when given it should be diluted with a con- 
siderable quantity of water; the dragees, granules, and compressed pills con- 
taining bromide should be discarded. I should add that when you are forced 
to increase the dose of this salt, as in epilepsy generally, you should require the 
patient to partake freely of milk, in order to avoid the gastro-intestinal irrita- 
tion which results from the prolonged use of the bromide in large doses. 

The quantity of bromide which ought to be administered daily is variable. 
From twelve to fifteen grammes a day have been given; the medium dose, in 
the majority of cases is eight grammes. This dose cannot be given from the first; 
you must begin with smaller doses, as one gramme morning and evening, and 
gradually increase the dose till you have obtained complete control of the dis- 
ease. Voisin thinks that we should regard as the maximum dose that which 
determines abolition of the reflex sensibility of the pharynx. I believe that 
this is an excellent rule in the case of hysteria, but not in epilepsy, and that in 
this disease we must not only attain abolition of the pharyngeal reflex irrita- 
bility, but we must, if occasion demand, push the administration of the remedy 
even farther, till we have stopped the attacks. But it is absolutely necessary to 
have a bromide preparation which is chemically pure, for Voisin has shown that 
the impurities of this salt considerably modify the therapeutical effects which it 
produces. 4 

These large doses of bromide, given for therapeutic effect, are not without 

lepsy. It is given in pill form (10 centigrammes, from one to two grains), one to ten pills 
being given a day. It is not a good preparation for hypodermic injection. (a) 

4 The purity of the bromide salt is a point of capital importance. It ought especially 
to be free from the iodide. To determine the presence of iodide of potassium, dissolve the 
suspected salt in starch water, add a few drops of nitric acid, and if there be any iodide of 
potassium present you will obtain a blue color from the formation of iodide of amyl. 
Lambert's method is even more delicate. Dissolve the bromide in a solution of potassium 
permanganate; if the bromide is pure the solution keeps its violet color, while it takes a 
yellowish tint if there are any traces of iodine present. According to Adrian a chemically 
pure solution of potassium bromide when treated by HC1, should evolve a few bubbles of 
C0 3 . Treated by one gramme of benzine, and a few drops of bromine water, it ought not 
to give a rose color. Treated by HNO s and nitrate of baryta, it ought not to turn yellow 
(Adrian: Researches on the Chemical Composition of Preparations of Bromide of Potassium, 
Bull. gen. de Ther., t. lxxvii., 1870; Lambert: How to Detect the Presence of KI in Brom- 
ide of Potassium, Bull. gen. de Ther., t. lxii., p. 503, 1867). 



(a) Lawson, on Monobromide of Camphor (Practitioner, April, 1875). Deneffe, on Bromide of 
Camphor and its Therapeutic Applications (Presse Med. Beige., 1871). Bourneville, Comptes Rend, des Obser- 
vations Recueilles a la Saltpetriere (Progres. Med., 1874, Nos. 32, 33, 39, 43). Pathault, on the Physiological 
Properties of Monobromide of Camphor (These de Paris, 1877). 



ON THE TREATMENT OF EPILEPSY. 121 

danger. They determine in certain patients a train of symptoms which in some 
instances have been grave enough to cause death, and to which the name 
bromism has been given. Besides the inconveniences mentioned in my lecture 
on hysteria, and which are the acne eruption, 1 the disagreeable odor of the 
breath, the peculiar unpleasant taste of the saliva, there are certain nervous 
manifestations of a grave kind, such as I lately observed in one of my patients 
who had taken in one day thirty grammes (a troyounce) of bromide of potas- 
sium. These symptoms consisted in a remarkable depression of the vital forces. 
The patient could not stand, could not make the least movement without diffi- 
culty. Intelligence was impaired, and there was aphasia and amnesia. 

This state, in which the patient is plunged into a most deplorable 
physical and moral brutishness, persists till elimination of the bromide by the 
various emunctories has taken place. 

These inconveniences of the bromide treatment are again and again ex- 
perienced by the epileptic patient, who finds himself often in a sad dilemma; 
either he must desist from the use of the remedy and see his fits come back, or 
persevere in the treatment, notwithstanding the depression of all his faculties 
and forces. Believe me, he will generally choose the latter as the lesser evil, 
rather than suffer those terrible attacks which are to the epileptic a menace 
always suspended over his head. 

But it is especially in the delirium of action, which makes the epileptic a 
criminal without his knowing it, that it is necessary to employ the bromide in 
massive doses in order to overcome the mania which impels him, unconsciously, 
to deeds of violence. Nothing, in fact, is more curious than to see in the wards 
of our lunatic asylums men enjoying their intelligence and their reason who 
have committed, and would still commit, the most astounding murders, if their 
maniacal propensities were not kept in check day by day by immense doses of 
bromide. 

How long should you continue the bromide treatment of epilepsy? Often 
a very long time, and even during the entire life of the patient. When, more- 
over, you have obtained the full benefit of the drug, and have witnessed com- 
plete cessation of the attacks, you must not leave off abruptly the medicine, but 
must keep on with it for several years, gradually diminishing the dose, as 
Legrand du Saulle has advised. 2 

1 Auguste Voisin was one of the first to indicate the bromide rashes; he ascribes four 
different kinds of eruption to the action of bromide. The most frequent is simple acne. 
The second kind is characterized by reddish patches, appearing oftenest on the calf of the 
leg. The third kind resembles erythema nodosum. The fourth is a watery eczema. 

Neumann, of Vienna, has studied microscopically portions of skin which were the seat 
of bromide eruption, and has shown that the bromine in being eliminated by the sebaceous 
glands, determines in these glands and their vicinity inflammations characterized by hyper- 
plasia of the epithelial elements. 

Guttmann has been more successful, and from acne postules, produced by the internal 
use of bromide of potassium, he has obtained on treating them with chlorine water and chlo- 
roform, the manifest reactions indicating the presence of bromine. 

2 His rules are as follows; We will suppose a case apparently cured. During the first 
year — fifteen days of each month with the bromide every day in the usual dose, and fifteen 



122 ON THE TREATMENT OF EPILEPSY. 

Under the influence of bromide medication, thus carried out, we witness 
mitigation, diminution in frequency, then disappearance — first of nocturnal then 
of diurnal attacks; then the vertiginous paroxysms and the aura cease, symp- 
toms which most resist the bromide treatment. These favorable results you 
will, as I said, obtain in one-half your cases. But you can often anticipate what 
will be the result of the bromide treatment by determining the cause of the 
epilepsy. Here Voisin (d) has given us valuable hints. The epilepsy which 
results from malformations of the cranium or cerebral tumors is rebellious to 
the bromide, while the functional and hereditary neurosis is amenable to this 
treatment. Sex has no influence one way or the other. 

Such, gentlemen, are the leading indications and methods of the bromide 
medication in epilepsy. If not absolutely and certainly curative, this medication, 
nevertheless, represents a real therapeutic progress when we consider the un- 
satisfactory nature of the treatment of olden times. I ought to add, as an item 
of interest in this connection, that experimental physiology has confirmed ordi- 
nary clinical results; I allude to the recent curious experiments of Albertoni,(^) 

days with the bromide every other day. In the second year — fifteen days of every month 
with the bromide every third day, and fifteen days with the bromide every day. In the third 
year — fifteen days of every month with the bromide every day, and fifteen days with the 
bromide every fourth day. In other cases (and this is now his habitual method), after the 
patient has gone one year without an attack, bromide treatment six days in the week. After 
fifteen months of freedom from attacks, bromide five days in the week. After eighteen 
months, bromide four days in the week. At the end of two years from the last attack, bro- 
mide only three days in the week, (Traitement et Curabilite de l'Epilepsie, by Legrand du 
Saulle). 

(d) Voisin thus formulates the prognosis of bromide treatment, in accordance with the 
causes of epilepsy, basing his views on ninety-six cases which he has treated: 

i. Epilepsy linked to a tuberculous inheritance, or to the presence of cerebral troubles 
as, for instance, when caused by traumatism, and malformations of the cranium, as well as 
when resulting from teething, is rebellious to bromide. 

2. Epilepsy caused by menstruation, by mental and emotional troubles, or by alcohol- 
ism in the parents is difficult of cure. 

3. Hereditary epilepsy was cured in four cases out of five. That caused by sudden 
fright; three cures and nine ameliorations; in three cases there was no improvement. Epi- 
lepsy following typhoid fever; four patients out of nine were benefited. 

4. Sex has not the least influence on treatment. Masturbation provokes the return of 
the fits, and all the other accidents, and hinders the action of bromide. The chronicity of 
the epilepsy has no influence on the bromide medication, (a) 

(<?)Albertoni performed an instructive experiment on some animals to which he gave 
for several successive days large doses of bromide; he was unable in these animals to pro- 
voke epileptic fits by irritating the cortex cerebri, although in animals not under bromide 
influence, convulsions are easily and surely so produced; when he had previously subjected 
his animals to moderately toxic doses of atropia, there was no protection whatever against 
fits when the surface of the cerebrum was excited, {b) 



(a) Voisin, on the Employment of Bromide in Nervous Diseases, Paris, 1875. Charles Simon, on 
Epilepsy, Divers Medications, Action of Bromide of Potassium on the Epilepsy of Insane Persons (These de 
Paris, 1880). 

(3) Albertoni, oh the Action of Certain Medicaments on the Cerebral Cortex, with reference to the 
Treatment of Epilepsy (Arch. Exp. Path, et Therap., t. XV, p. 3 and 4). 



ON THE TREATMENT OF EPILEPSY. 123 

who, after prolonged administration of the bromide to animals was not able to 
induce in them experimental epilepsy by irritating the cerebral cortex, although 
after giving atropine under like circumstances such convulsive attacks could 
easily be provoked. 

Other remedies which act on the medulla oblongata, or on the muscular 
system, have been prescribed in epilepsy, such as picrotoxine, 16 bromide of 
gold, 1 curare (g), and nitrite of sodium (/). 

Curare or wourari has been tried hypodermically in epilepsy by Voisin 
and Liouville; the effects are not sufficiently encouraging to warrant continued 
use of this medicament, notwithstanding the more recent trials of Edelfsen and 
Kunze. Picrotoxine, 2 the active principle of cocculus indicus, has been made 

1 Bourneville has given bromide of gold for a period of seven months to a certain 
number of epileptics; he gives it in the form of pills containing one centigramme (% grain), 
of these, ten a day; he reports no favorable result from this treatment. 

(jf) Kunze employs curare in the treatment of epilepsy, and makes use of the following 
solution: 

1$ Curare 0.50 

Distilled water 5 . 00 

Hydrochloric acid, one drop. 

M. Digest twenty-four hours and filter. One third of this solution is injected every 
five days. If there is no amelioration at the end of the fifth injection, Kunze would abandon 
the treatment. Out of thirty-nine cases he has obtained nine cures, (a) 

(/) Law has employed nitrite of sodium in epilepsy. He gave one gramme (15 grains) 
a day, and under its influence the fits disappeared. Nitrite of sodium acts like nitrite of 
amyl, and nitro-glycerine. 

Henry Ralf has used the same medicament, and has found it useful in cases where bro- 
mide is without result, or badly supported. It would seem, however, from the report of the 
London Medical Society that the effects of sodium nitrite are not to be depended on. {b) 

2 Boullay was the first to extract picrotoxine from cocculus indicus. This substance 
(C 6 H 6 O 2 ) has been studied from a physiological point of view by Glover, Bonnefin, Brown- 
Sequard, Vulpian, etc. Glover affirms that this poison has a quite special action on the 
cerebellum and tubercular quadrigemina. Vulpian has shown that the convulsions which 
take place in animals poisoned by picrotoxine, are due to the excitant action of this substance 
on the anterior portions of the cerebro-spinal axis, and particularly on the medulla oblongata 
and pons. Varolii, Chiroine and Testa have obtained a true artificial epilepsy in employing 
picrotoxine. Moreover, according to Chirone, picrotoxine is not a pure alkaloid, and is 
composed of three other substances, which are picrotoxin, properly so-called, which is bitter 
and toxic; picrotine, which is bitter and not toxic; and anamirtine, which is neither bitter 
nor toxic. Planat, of Valorville, basing himself on the action of picrotoxine on the bulb, has 
counselled this substance under two forms; the tincture of cocculus indicus and solution of 
picrotoxine. The tincture is made thus: 

{a) Bourneville, on Bromide of Gold in Epilepsy (Progres Medlcale, Feb. 3, 1883, p. 87). Kunze, on 
the Treatment of Epilepsy by Curare (Med. Chir. Revue, Oct., 1881). Edlesfsen, on the Treatment of Epi- 
lepsy by Subcutaneous Injections of Curare (Berlin Woch., July 4, 1881). 

(6) Law, on Nitrite of Sodium in Epilepsy, Practitioner, June, 1882. Reports of Medical Society of 
London, Nov. 28, 1882, and Bull. Gen. de Ther.. Jan. 30, 1883. 

[There is no doubt that many epileptics are temporarily benefited by momentary inhalations of a few 
drops of nitrite of amyl inhaled from the palm of the hand or from a handkerchief. Taken during the aura 
it is often successful in averting a fit. Epileptic vertigo is also alleviated by it. It is not, however, a remedy 
to be much relied on. — Trans.] 



124 ON THE TREATMENT OF EPILEPSY. 

the subject of study by Brown-Sequard, Glover, Bonnefin, Vulpian, and others. 
These researches show that picrotoxine has an elective action on the medulla 
oblongata, and may even determine a veritable experimental epilepsy. Planat 
has utilized this special selective. action of picrotoxine in the treatment of epi- 
lepsy; I have myself experimented with it, but have not obtained favorable 
results except in alcoholic epilepsy — which will get well of itself if the patient 
will practice abstinence from alcohol. Vulpian has also tried it without success. 
Add that picrotoxine is very poisonous, even in small doses, and we ought to 
conclude that this medicament should have a very humble place in the treat- 
ment of epilepsy. 

Finally, Huchard has recently advised the association of digitalis with 
bromide in the treatment of epilepsy, and claims good results from the combina- 
tion. 

Thus far we have been occupied only with the general or pharmaceutical 
treatment of epilepsy; it remains to speak of the hygienic treatment, and of that 
of the attacks. 

If hygiene has not a preponderant part in the treatment of epilepsy, never- 
theless it is not without influence on the production of the attacks. Here, as 
in hysteria, the question of marriage comes up for consideration. Ought an 
epileptic to marry? It is well to bear in mind, and to urge upon your clients, 
when they consult you in reference to the marriage of an epileptic, that epi- 
lepsy, with all its gravity, is not necessarily and fatally hereditary, and in giving 
this opinion you can fortify yourself by the authority of professor Lesegue, 
than whom no one is more qualified to judge on questions of this kind. In 

1$ Cocculus Indicus I part. 

Rectified spirits 5 parts, 

M. Of this tincture two drops are given the first day, one morning and night, and the 
dose is increased each successive day till fifteen drops are taken morning and night. The 
solution has the following formula: 

1$ Picrotoxine o. 03 

Alcohol 10.00 

Distilled water 110.00 

M. The dose is one half teaspoonful morning and night, and at the end of a fortnight 
the dose is increased to a teaspoonful. 

Planat claims to have cured by this means many cases of epilepsy without ever exceed- 
ing a quantity of three milligrammes of picrotoxine a day. Dujardin-Beaumetz has obtained 
no results from it except in alcoholic epilepsy which may get well of itself. 

Vulpian considers this kind of treatment as very dangerous, and he has seen no good 
from it. (a) 



(a) Glover, Monthly Jour, of Med. Sciences, April, 1851. Bonnefin, These de Paris, 1851. Planat, 
Physiological and Therapeutic Researches on Picrotoxine. Application to the Treatment of Epilepsy (Jour, de 
Ther., Nos. 10, 11, 12,1874.) Cayrade, a Study of Convulsivant Poisons, Paris, 1866. Vulpian, Action 
Physiologique des Substances Toxiques, Paris, 1882, p. 623. Chirone and Testa, Experimental Researches 
on the Physiological Action of Picrotoxine (Union Med., May 21, 1881). Dujardin-Beaumetz, Soc. de 
Ther., 1875. 



ON THE TREATMENT OF EPILEPSY. 125 

fact, Lesegue 1 denies the hereditary nature of epilepsy. This is a matter of 
considerable importance, and holding this view we are enabled to tone down 
somewhat the sombre colors in which such a union would otherwise be in- 
vested. 

If continence does not play an important part, it is not the same with ven- 
ereal excesses, which have a most decided influence in the production of at- 
tacks. Masturbation is most pernicious to epileptics, and destroys, in a certain 
measure, the effect of treatment by bromides. 

Epileptics should live in the country and avoid crowded assemblies, politi- 
cal gatherings, concerts, shows, and the like. You must often have remarked 
that theatrical exhibitions are frequently interrupted by attacks of epilepsy, and 
this for the reason, principally, that the bad air and the heat of the apartments 
are deleterious to epileptics. 

The alimentary regimen has a certain influence on the falling sickness. 

1 The affirmation of Lesegue is so important that we reproduce here the entire para- 
graph: "Epilepsy, a disease of evolution, is not hereditary. This proposition seems to 
have excited considerable surprise, which I scarcely comprehend, so little is there that is 
new about it. I hardly need defend so patent a fact, but perhaps something by way of com- 
ment may be appropriate. The formula of hereditary epilepsy, if such existed, would be 
that of inheritance generally. Epilepticus autem gemrit epilepticum (the epileptic begets an 
epileptic). But statistics (and how numerous they are), have sufficiently proved that such 
direct begetting is the exception. Epilepsy so i-arely transmits itself as never to have given 
rise to a popular saying of this sort (for which there would in fact be no justification), "to 
an epileptic father belongs an epileptic son." For a stronger reason a medical aphorism of 
this sort is inadmissible. In this respect epilepsy resembles deaf muteness by vice of devel- 
opment, and there is moie here than simple coincidence. Must we conclude, then, that 
epilepsy, an autochthonous affection, arises by spontaneous generation, borrowing nothing 
from ascendants? Far from it. It is one of the diseases on whose genesis the health of 
parents has the most influence, but in an indirect, or as we might say, round-about way, 
as in the case of deaf muteness just referred to. There are very generally family diseases 
of a character kindred to epilepsy. The ascendants were neuropathic, at some time in their 
life manifested mental alienation, or at least were distinguished for eccentricity. There is, 
perhaps, a history of consanguineous marriages; the parents were given to debauch- 
eries of every kind. The epileptic belongs to a race physically and intellectually de- 
generated, or he has brought this organic deterioration on himself. He has been given to 
alcoholic excesses, to low vices, to various degrading pursuits. Parallel with the inheritance 
of epileptic tendencies, we often find members of such families that are idiots, that are de- 
formed, or otherwise unsound in mind or body. I have often been consulted as to the ad- 
visability of an epileptic marrying. The reply is easy enough, considering the incurability 
of the disease, and the gloomy future before the patient. Such marriages are not to be en- 
couraged, but how is it with the children that may be born of them? What will be 
likely to be their future fate? Far be from me any denial of the disastrous consequences 
which may follow such unions. I only reserve for myself the right to deny as an absolute 
impediment to marriage, the probability of hereditary epilepsy. I cannot affirm with the 
same confidence that there will be immunity from other grave affections of the nervous sys- 
tem. Just as a neuropathic parent engenders, under certain circumstances, an epileptic 
child, so also the epileptic father may beget, according to the law of hereditary transforma- 
tion, a healthy child, an idiot, a confirmed nervous invalid, or a lunatic. You would have to 
use the term in a sense different from the ordinary sense, to call these modes of transmis- 
sion, or rather of influence, hereditary epilepsy. 



126 ON THE TREATMENT OF EPILEPSY. 

First of all, the alcohols are themselves a cause of epilepsy, and you are not 
ignorant of the studies of Magnan as to alcoholic epilepsy, and in particular 
that form of epilepsy which is produced by absinthe; 1 it is proved that these 
nerve-excitants produce epilepsy in men and animals; you ought then to inter- 
dict the use of alcoholic beverages to your patients. 

You ought also to advise a diet which shall contain nitrogenous substances 
in very sparing quantity. It seems, in fact, proven that a vegetable diet dimin- 
ishes in a marked manner the number of attacks, while an azotized diet consid- 
erably increases them; the epileptic, then, should be strictly vegetarian. To 
sum up the rules of hygiene, the epileptic patient should live much in the open 
air, be very moderate in sexual indulgences, take a great deal of exercise, ab- 
stain from spirituous liquors, and live almost exclusively on vegetable food. 

As for the treatment of the attack, it consists in placing the patient in a 
horizontal position, and loosening any part of his apparel which may cause 
constriction of the neck or thorax. It is generally customary to place some 
hard substance (as a clothes-pin) in the mouth of the patient to prevent biting 
of the tongue, a means which has not been very successful; the foreign body, 
if too resisting, breaks the teeth of the patient, and if too little resisting, is 

1 When spirit of absinthe is introduced into the stomach or veins, toxic phenomen- 
are observed, which vary in intensity according to the dose. A small dose causes short, 
quick, convulsive movements, or shocks like battery discharges, affecting principally the 
neck and the fore limbs; the same dose determines a vertigo very similar to epileptic ver- 
tigo, but the resemblance is much more striking when larger doses are used. Then veritable 
epileptic attacks ensue, characterized at first by tonic succeeded by clonic convulsions; the 
animal froths at the mouth, the tongue is bitten, and there are involuntary evacuations of 
urine, of fecal matters, and of sperm. These attacks, which last several minutes, may be 
renewed at intervals varying from ten to twenty minutes or more. In the intervals of the 
paroxysms the animal seems dull and listless, and gradually comes completely to himself. 
Animals deprived of their cerebrum, like those that have not undergone this mutilation, ex- 
perience epileptiform attacks under the influence of essence of absinthe. If section is made 
of the cord below the medulla oblongata, the epileptic attack shows two well-marked stages; 
you note first the tonic and clonic convulsions of the head with froth in the mouth, this may 
be called the bulbar attack; then ensue general convulsions of all the muscles of the 
body, with expulsion of urine and fecal matters, this is the spinal attack. In animals pois- 
oned by essence of absinthe, one always finds, even at the commencement of convulsive 
accidents, a bright injection of the optic disk and dilatation of the pupil. This congestion 
is not limited to the retina, but affects the whole brain. In fact it is easy to observe when 
trephining of the cranium has been practiced in the first stage of absinthe poisoning, and in 
the commencement of the attack, a very intense congestion of the encephalon. In man the 
prolonged and daily use of absinthe determines a series of symptoms which have been des- 
ignated and described under the name of absinthism, and which have been studied by 
Mottet, Magnan, Challaud, Lancereaux, Rodet, Smith, Voisin, etc. (a) 



(a) Magnan: Epilepsie Alcoolique, Action sp^ciale de l'Absinthe, Compt. Rend, de la Soc. Biol., t xiii, 
Paris, 1869; Rodet: Troubles Caused by the Abuse of Alcohol and of Absinthe. Gaz. M^d. de Lyon, t. xvi, 
pp. 590-592, 1864; Dujardin-Beaumetz: Art. in Absinthe, in Diet, de Ther., 1882. John Mersin: Influence of 
Food and Hygiene in Epilepsy, West Riding- Lunatic Asylum Med. Reports, 1875; Bourneville et Oilier: 
Recherches sur l'Action physiologique du Bromure d'Ethyle dans l'Hyst^rie et l'Epilepsie, Gazette M£d. de 
Paris, No. 35, 1880; Bourneville: Du Nitrite d'Amyle dans l'Epilepsie, Soc. de Biol., June, 1875.) 



ON THE TREATMENT OF EPILEPSY. 127 

liable to be bitten off in the struggle, and to find its way to the throat or wind- 
pipe of the patient, causing suffocation. 

Certain measures have been advised to prevent the convulsive seizures, 
such as the energetic flexion of the great toe, compression of the temporal re- 
gions, of the infra-occipital hollow, etc. Others have counselled by various 
compressions to prevent the aura from spreading; Rozier has even devised a 
special instrument for this purpose. All of these means are only of use in 
certain exceptional cases where the epileptic has premonition of his attack by 
sensations of aura which precede the convulsive seizure by a brief interval. It 
has also been proposed to employ during the paroxysm, hypodermic injections 
of apomorphia, 1 inhalations of bromide of ethyl, and nitrate of amyl. 
Bourneville has given us some interesting facts relating to the two last medica- 
ments but these inhalations have not come into general use. 

This finishes what I deemed important to say relative to the treatment of 
epilepsy, and the beneficial influence of therapeutics in this terrible disease. 
In the next lecture I shall consider chorea and its treatment. 

1 Vallander, of Brauweiler, has in three cases arrested epileptic attacks preceded by 
an aura, by subcutaneous injections of apomorphine. He is in the habit of injecting subcu- 
taneously, a minute dose (not exceeding a twelfth of a grain) of apomorphia. The injection 
does not cause vomiting, though it produces a little nausea, (a) 



(a) Vallander, on Cutting- Short an Epileptic Fit by Subcutaneous Injections of Apomorphia (Berlin Klin 
Wochens. No 14. p. 185, 1877). 



ON THE TREATMENT OF CHOREA. 

Summary. — Different Kinds of Chorea — Curability of Chorea — Pathogeny of Chorea — ■ 
Divers Medications Proposed — Muscular Medicaments — Strychnine — Aniline — Eserine 
— Curare — Medullary Medicaments— Picrotoxine — Hyoscyamine — The Bromides — 
Electricity — Galvanic Baths— Ether Spray — Anaesthetic Medicaments— Morphine — 
Chloral — Chloroform— Medicaments that Act on the General Condition — Tartar 
Emetic — Blood-Letting — Hydrotherapy — Sulphur Baths — Gymnastics. 

Gentlemen — From the standpoint of therapeutics, what distinguishes 
chorea from the other neuroses which we have been considering, is its spon- 
taneous march toward recovery. This is a fact of capital importance and has a 
preponderant bearing on the discussion in which we are about to enter. 

Chorea 1 in fact presents, like all the cyclical diseases, a period of increase 

1 Chorea (St. Vitus' dance, St. Guy's dance) is a disease of the second period of child- 
hood and of puberty; its maximum frequency is from the age of n to 15, and 15 to 25. It 
may, however, show itself at all ages of life, and is more frequent in females than in males. 
It is acute or chronic, general or partial, continuous or intermittent, and may, in accordance 
with its causes, be divided into hysterical, rheumatic, saturnine, etc. The onset of the 
disease may be sudden and marked by an epileptiform or hysterical attack after a fright 
or a strong emotion, but almost always its development is slow and gradual, and it an- 
nounces itself by a change in the character, the intelligence, and the habits of the patient; 
the child becomes ill-natured, impressionable and irritable, forgetful, inattentive and idle; its 
voluntary movements are jerky and incoordinate. When the disease is confirmed, in- 
voluntary movements make their appearance, commencing by the face, one of the arms or 
one hand (ordinarily the left), then they gain the trunk and the lower extremities; these 
choreic movements at first light, soon increase in intensity and become general, attack the 
muscles of the arms and legs. 

In order to seize an object the patient executes a series of jerky movements, or projects 
vehemently his arms forward, over-reaching his end, or hits the object without being able to 
grasp it. He cannot grasp a small object or he lets it fall; he cannot carry his cup or 
his food to his mouth without spilling a portion. His manner of walking is uncouth and 
jerky; he walks zig zag, his legs cross each other and frequently a fall is the consequence. 
The face is the seat of irregular contractions, twitchings; the forehead wrinkles and again 
becomes smooth; the eyebrows corrugate spasmodically, the eyelids wink in a lively manner; 
the lips open and shut, the mouth is the seat of grimaces; the visage in a word, executes a 
series of movements, and expresses in a brief space of time sentiments the most diverse. 
The muscles of the tongue, of the larynx and of the pharynx are affected also. The tongue 
is thrust violently out of the mouth, executes divers movements which prevent the patient 
from speaking intelligibly; there are even children who are so conscious of their condition 
that they seem to hesitate before speaking, slowly meditating what they wish to say. The 
troubles of the tongue and pharynx impede deglutition; those of the larynx give a hoarseness 
to the voice. When the limbs are affected there is no rest; the child moves about from 
place to place; whether sitting or lying down, its members execute abrupt constant movements, 
so dangerous even, that it is often necessary to put on the strait-jacket, or to protect the 
bed on which the patient lies, and even the walls, with boards or cushions, so as to keep him 
from falling, or to deaden the effects of the blows. The movements are persistent and rap- 
idly wear out the bed clothes, and cause irritation with excoriation of the skin. When the 
patient wills to execute a movement it seems that the very desire and attention are excit- 

128 



ON THE TREATMENT OF CHOREA. 129 

or ''augment," a stationary period, " fastigium," and a period of decline; it 
passes through all these stages in an average time of two to three months, and 
you well understand that this spontaneous tendency toward cure modifies the 
results obtained by an appropriate treatment, according as such treatment is 
instituted at the beginning or decline of the disease. Therefore, whenever you 
would appreciate the value of any kind of internal medication directed against 
chorea, you should base your judgment, not on the duration of the treatment, 
but on the entire duration of the disease; and when the latter corresponds 
pretty closely with the normal and spontaneous evolution of the malady, you 
may conclude that the medicine has been of little utility. 

From such considerations, moreover, we ought utterly to abjure all violent 
modes of treatment, which may become dangerous by the troubles which they 
are likely to occasion in the organism. Death is fortunately rare in chorea, 
but does sometimes happen in consequence of excoriations produced by the 
disorderly movements of the child. 

What I have to say on this occasion will concern true chorea, that ordi- 
nary form of motor incoordination which affects childhood and develops, as See 
and Roger have shown, under the influence of rheumatism. 2 I leave, then, 

ants of the inco-ordination, and develop an ataxic condition of the muscles {folie 7?iusculaire). 
The child executes a series of strange movements and contortions before being able to touch 
the object that it desires. Except in very violent cases of chorea these movements cease 
during sleep. The sphincters are affected in some cases. According to Spetzmuller and 
Benedekt, the heart muscle may also be affected. The sensibility is troubled in different 
ways; pains in the temples, the forehead, the back of the neck, the muscles, formications, 
numbness in the limbs or joints; anaesthesia and hyperesthesia of the skin, and there are 
often painful points over certain nerves. In hemichorea, symptomatic of a cerebral lesion, 
hemi anaesthesia is frequently observed. The memory, attention, intelligence are all lost; 
the character is changed; the patient is indifferent, changeable, good natured or passionate, 
and becomes very timid. You also observe hallucinations, diurnal or nocturnal, sometimes 
even maniacal delirium. All these divers troubles have an influence on the general condition; 
there are palpitations of the heart, often intermittences, irregularity in the beats (chorea of 
the heart), cardiac pains; the digestive functions are disturbed; there is anorexia, flatu- 
lence, often constipation and anaemia, or chloro anaemia, develops rapidly. In young girls 
menstruation ceases or becomes very irregular. Chorea has an average duration of two to 
three months; it may last longer than this, rarely has a shorter run. Fatal terminations are 
quite infrequent, yet death may take place either suddenly by cerebral rheumatism, or slowly 
by nervous exhaustion as a consequence of insomnia, extreme agitation and delirium; the 
excoriations, the wounds and bruises, the phlegmons caused by the disordered movements 
of the little patient often induce prolonged suppurations which cause death. Ordinarily 
chorea gets well without passing to a state of chronicity, or leaves after it nothing but facial 
spasms {tics de la face, a sort of partial chorea). Relapses are frequent; they often break out 
in autumn, at the period of puberty, on the occasion of pregnancy, but the attacks become 
less and less long and less intense. Chorea of pregnancy develops especially in primiparae 
and in the first four months of gestation; it predisposes to abortion or premature accouche- 
ment. 

2 The causes of chorea are predisposing and exciting. Among the former we reckon 
age, sex and heredity. The disease, rare in warm climates, is oftener seen in winter than 
in summer. Very frequent between the age of 15 and 20, it has been observed in very 
young children (Simon and Constant report cases in infants not a year old;, nor is it rare 
between the ages of 35 and 50; Charcot has seen chorea at the age of 70 years, Roger at 83, 



130 ON THE TREATMENT OF CHOREA. 

completely to one side those symptomatic choreas and all those disorders of 
movement which have been described under the name of " St. Wyt's dance " 
(dancing chorea), and all those partial choreas and rhythmical twitchings of 
muscles which are referred to athetosis, disseminated sclerosis, to paralysis 
agitans or simple nervous debility. 

The causes of chorea are predisposing and determining. Among the first 
are age, sex and heredity. The disease, rare in warm climates, is more fre- 
quent in winter than in summer. It is observed between the ages of eleven 
and twenty, rarely between thirty-five and fifty, and occasionally in advanced 
life. It is much more frequent at the age of second dentition, or at the period 
of puberty. It is also more frequent in females than in males. Heredity plays 
an important part. Children inherit this neurosis from choreic parents, or it 
may be that epilepsy, hysteria, etc., are family diseases. Venereal excesses and 
masturbation predispose to chorea. 

The determining causes are numerous: Strong emotions, fright, anger, 
may produce it. It is sometimes seen in the course of a protracted fever, or 
during convalescence. Pregnancy, menstrual irregularities, uterine affections, 
are causes of chorea. 

Among the most powerful causes are articular rheumatism, endo-pericar- 
ditis, intestinal worms and ansemia. 

The relation of rheumatism to chorea has long been noted. In France it 
has been studied by Germain See and H. Roger, who consider chorea a rheu- 
matic affection. This opinion has been vehemently combated by Grisolle, 

but its greatest frequency is at the time of second dentition, or at the period of puberty. It 
is more common in females than in males. Heredity plays an undoubted part, and children 
inherit this neurosis from parents that were choreic, hysteric, or epileptic. Venereal excesses, 
onanism, by the nervous exhaustion which they entail, predispose to this disease. The excit- 
ing causes are numerous; strong emotion, fright, anger may provoke the disease, and it is 
not rare to see it manifest itself during the course of continued fever or during convalescence. 
Pregnancy, menstrual troubles, uterine affections, are all causes of chorea. Among the 
most powerful causes we include articular rheumatism, intestinal worms and anaemia. The 
relation of rheumatism to chorea has been long remarked. In France it has been studied 
especially by Germain See (1850), and H. Roger, who consider true chorea as a rheumatic 
affection. This opinion, however, is not accepted by all; (for instance, by Rilliet and 
Barthez, Barrier, Grisolle, Monneret, Graves, Niemeyer, Empis). According to See the coin- 
cidence between chorea and rheumatism is so frequent that out of every two rheumatic 
children, one will be choreic. Chorea may, moreover, show itself in the course of rheuma- 
tism, precede it, or alternate with attacks of rheumatism. Roger has, moreover, shown that 
chorea may manifest itself in children that have had rheumatism, that it appears a little 
while after the rheumatism, or as a complication. 

It may develop at the period of decline of rheumatic fever, or may attend the cardiac 
manifestations of rheumatism (pericarditis, endocarditis), when there are no joint manifesta- 
tions. In these cases the chorea either precedes or succeeds the cardiopathy; it may, 
however, occur simultaneously. 

Some authorities consider the cardiac lesions as the starting point of the neurosis, the 
disease having for origin irritation of the nerves of the heart (Bright and E. Cyon). 

According to Hughlings Jackson, Tuckwell, and others, chorea is due in these cases 
to cerebral embolisms, caused by pre-existant endocarditis ; these emboli occurring in 
the corpora striata. • 



ON THE TREATMENT OF CHOREA. 131 

Graves, Niemeyer and others. According to Professor See, the coincidence of 
chorea and rheumatism is so striking, that out of every two children affected 
with rheumatism, one of them becomes choreic. Roger also has shown that 
chorea manifests itself often in children who have had rheumatism; and that it 
accompanies or immediately succeeds that disease. 

Its existence frequently coincides with the cardiac affections of rheumatism 
(endocarditis, pericarditis). Certain authorities consider the cardiac lesions as 
the point of departure of the neurosis. Bright and Cyon think that it is due to 
irritation of the nerves of the heart. Hughlings Jackson and Tuckwell trace 
its origin to cerebral embolisms caused by a preexisting endocarditis; the em 
bolic infarctions being in the corpus striatum. 

Like every disease which tends of itself toward recovery, chorea has re 
ceived a variety of treatments; it has been natural to attribute to the medicine 
given the cure which one has observed. Therefore, in order to give system to 
the details into which I am about to enter, I shall have to range these treat- 
ments in different classes, and we will study them under four heads. 

In the first group we shall examine muscular medicaments. Struck by the 
ataxia of movements characterizing the disease, certain physicians have essayed 
to cure chorea by means absolutely opposite; one class of remedies augmenting 
muscular contractility, like strychnia and aniline, another destroying it, like 
eserine and curare. 

In the second group we place medicaments addressed directly to the spinal 
cord. Although the latest researches have attributed to a cerebral origin the 
clonic movements which are observed in chorea, a preponderating role in the 
production of this neurosis has always been assigned to the spinal cord and its 
membranes, and authorities have even gone so far as to pretend that it was 
only the result of a rheumatic affection of this part of the cerebro-spinal axis. 
You will not, then, be astonished to learn that medicines addressed particularly 
to this supposed medullary affection have been recommended, such as bromide 
of potassium, oxide of zinc, the ether spray and applications of ice along the 
spinal column. 

It is upon an altogether different basis that is established our third class 
of medicaments. Noting that sleep arrests choreic movements, some have 
thought that by artificially producing sleep, they might stop the muscular dis- 
order. Therefore chorea has been treated by soporifics, such as opium, chloro- 
form and chloral. 

Finally, in a fourth and last group, I place those medicaments which are 
directed to the state of the vital forces, and here, as in the case of the first 
class, we have two kinds of treatment diametrically opposed; in the one are the 
depressants, such as tartrate of antimony; in the other tonics, such as arsenic, 
hydrotherapy, sulphur baths and gymnastics. 

Let us examine the first of these groups, the muscular medicaments. In 
this group we have the tetanizers and the paralyzers of muscles. It was Trous- 
seau who first brought into vogue the treatment of chorea by strychnia, though 
this drug had previously been employed by Lejeune, Neumann and Cazenave 
of Bordeaux. Trousseau prescribed very large doses of strychnia, giving five 



132 ON THE TREATMENT OF CHOREA. 

and even ten centigrams of strychnia daily (from one to two grains) to choreic 
patients, and determining tetanic contractures of the masseters. Despite the 
support which West has quite recently given to this treatment, and the favor- 
able results cited by Lacaze Duthiers and others, notably by Hammond in 
America, I have not seen any benefit from such heroic medication, and cannot 
advise it, being persuaded of its inefficacy and its danger. 1 

I must say the same of aniline, 2 which is, as you know, a convulsivant poi- 
son, which Turnbull, Filiberti and Frazer have employed in chorea. 

By the side of these convulsivant medicines I must place those which have 
an opposite action, namely, the paralyzers of muscle. I shall pass by curare and 
curarine, which have been employed by Drummond, Day and Fulton, remedies 
whose utility in chorea is still sub judice? and shall make brief mention of the 
alkaloid of Calabar bean. 4 

1 Instead of translating a long foot note of the author giving the French method of giv- 
ing strychnia, popularized by Trousseau, I present Hammond's method, from his Treatise on 
Nervous Diseases. He makes a solution of strychnia one-half the strength of the liquor 
strychniae of the P. Br.; thus: 1$ Strychniae, gr. j.; aquae, § ss. Dose, five drops t. i. d. to 
a child from ten to fifteen years of age. The dose should be increased by one drop daily till 
the physiological effects of the medicine are manifested, as evidenced by stiffness of the 
legs and neck. When this takes place the dose should be reduced to five drops and increased 
as before. * 

2 Aniline or phenylamine (C 6 H 7 N) is the first term of a series of aromatic alkaloids; it 
was formerly obtained from indigo. It is now obtained from coal-tar. In toxic doses 
aniline produces eclamptic attacks, and first excites, then paralyzes the nervous system. 

Turnbull gives aniline in doses of from three to five grains, increasing gradually the 
dose up to fifteen grains, (a) 

3 In the London Lancet (reprint) for 1879, P- 35 2 » i s an interesting report of cases 
treated in the Samaritan Hospital by hypodermic injections of curare (service of Dr. Day). 
One-sixtieth, one-fortieth, then one-tenth of a grain, daily, was injected. The latter dose 
calmed and improved the patient in every way for thirty hours. Dr. Day followed up the 
benefit derived by giving sulphate of zinc, three grains, t. i. d. Dr. Drummond, of New- 
castle-on-Tyne, had previously treated and cured an obstinate case of chorea by the subcu- 
taneous injection of curare. (British Medical Journal, June 15, 1878, p. 857.) The curare 
was in small square discs of i-6oth grain, prepared by Savory & Moore; these discs were 
soluble in three or four drops of water. Dr. Day remarks that chorea, which has hitherto 
been regarded as a spinal disease, seems, in consequence of the association of mouth move- 
ments with movements of the limbs, to have a decided cerebral aspect. The experiments of 
Hitzig and of Ferrier show that the centres for movements of mouth and limbs lie close 
together in the motor area of the brain. The hypothesis then suggested itself that chorea 
might be the result of a rippling discharge from the motor centres lying around the fissure of 
Rolando. The possibility that this may be the case renders the therapeutics of this affection 
still unsettled and unsatisfactory. 

4 Bouchut has employed sulphate of eserine in 437 cases of chorea and of convulsive 
neuroses in infants from seven to twelve years of age. In 205 cases the medicament was 
introduced into the stomach in the form of pills of fa to fa of a grain. In 232 other cases it 
was administered hypodermically in the same doses. When sulphate of eserine is injected 
under the skin in doses varying from fa to fa of a grain, you first observe nausea and 



(a) Turnbull, on the Physiological Properties of Sulphate of Aniline and its Use in the Treatment of 
Chorea (Lancet, 1861). Filiberti, on Aniline in Chorea (Gaz. Med. de Lyon, 1864). D. Beaumetz, Art., 
Aniline, in Diet, de Ther. 



ON THE TREATMENT OF CHOREA. 133 

Eserine has been recommended in the treatment of chorea by Bouchut. It 
is to him that we owe the greatest number of observations, some 437 cases of 
chorea having been treated with eserine by this practitioner. Despite the 
advantageous results claimed for this method, since, according to Bouchut, an 
average of eight days of treatment suffices in the majority of cases for a cure, 
this medication has not been received with favor, and I know of no one at the 
present day who employs it. It is, in fact, a dangerous treatment, nausea and 
symptoms of paralysis of the diaphragm following the absorption of this 
alkaloid; and, although no grave accident was observed in the cases reported 
by Bouchut, serious evil is likely to result from the use of this powerful toxic 
agent. 

The same dangers attend the use of hyoscyamine, the favorable effects of 
which in the treatment of tremblings in general, and of chorea in particular, 
Oulmont has taught us. 5 The danger results chiefly from the unreliability of 
the preparation; there exist, in fact, in commerce, hyoscyamines of variable 
intensity, and one obtains different effects according as he uses the preparations 
of different pharmacists. Recently, at the Societe des Hopitaux, our col- 
league Empis reported grave toxic symptoms following doses of 5 milligrams 
of hyoscyamine. 

All these alkloids, whose action is so energetic, ought to be discarded in 
chorea, for the risk attending their use is out of proportion to the problematical 
benefit derived from them, in the case of a disease which runs a definite course, 
with predominating tendencies toward recovery. 

Our second class of medicaments is constituted of those which are 
addressed particularly to the spinal cord, whose excito-motor power they dimin- 
ish. At their head is placed bromide of potassium, a precious medicament, 
which we have already seen employed with so much success in the treatment of 

malaise, then sweat rolls from the face, there are cramps in the stomach, vomiting, and 
paralysis of the diaphragm. The action of eserine introduced into the stomach is much less 
marked than by subcutaneous injection, and ^ of a grain by the mouth corresponds to jfa of 
a grain under the skin. Bouchut has compared the results in animals and in men, and has 
shown that they do not agree. In the treatment of chorea by eserine, Bouchut obtained a 
cure in an average of ten days ; should the eserine lose its effect, he caused the injection 
to be repeated three or four times a day, giving each time from ^ to -^ of a grain, so 
that every day the patient would receive i to J of a grain. Cadet de Gassicourt has repeated 
this experiment in four cases, and has obtained no result whatever, therefore he discards 
this treatment, (a) 

5 Oulmont has treated five patients affected with chorea and aged from 20 to 36 years, by 
hyoscyamin, and has obtained favorable results. He administers hyoscyamin in pills of -^ 
of a grain, until amelioration is produced, but never exceeds 10 pills a day. According to 
Oulmont, chorea is one of the neuroses which seems to be the most favorably influenced by 
this medicament, (b) 



(a) Bouchut, Therapeutical Researches on the Action of Eserine in Chorea (Bull, de Ther., t. 88, 187s, 
p. 89, and t. 89, p. 541). Cadet de Gassicourt, note on the Employ of Sulphate of Eserine in Chorea, Jour, de 
Ther., 1875, p. 541). 

(5) Oulmont, on Treatment of Chorea by Hyoscyamin, Bull, de Ther., t. 89, 1875, p. 145. Brochin. 
Treatment of Chorea by Hyoscyamin, (Gaz. des Hop., 1875, p. 1018). 



134 ON THE TREATMENT OF CHOREA. 

epilepsy and hysteria. It has also found a place in the treatment of chorea, 
and Kohn has shown us what to expect from the bromide in this affection. 1 

For my part, I believe it is in the hysterical choreas that the bromide treat- 
ment does the most good. You know, in fact, that chorea is often a mani- 
festation of hysteria, and the happy influence of the bromide in these cases is 
easily understood. In the chorea of children, however, the bromide is very far 
from being as efficacious, and, notwithstanding the facts presented by Gubler, 
Gallard, Hough, Worms, and Tarchetti, I share the opinion expressed by 
Ziemssen, Steine, and Dally, and believe that bromide of potassium is not of 
utility in ordinary chorea, unless, indeed, administered in doses sufficient to 
produce bromism, and here the disadvantages are out of proportion to the 
advantages derived. 

In England and the United States sulphate of zinc is much used in the 
treatment of chorea. Barlow at Guy's Hospital, West and Butlin, in England, 
and Hammond, of New York, speak highly of this medicament, which is given 
in doses of a grain or two, gradually increased .till as much as fifteen or twenty 
grains are taken three times a day. As this salt is very irritating to the stom- 
ach, it has been proposed to give it largely diluted. 2 

In France we rarely use this medicament, which in many points bears a 
resemblance to internal metallotherapy; and just as to the treatment of certain 
hysterical symptoms it has been of late customary to apply magnets and me- 
tallic armatures, so also it has been proposed to treat chorea by this method, 
and Burq, in 1859, reported cases of St. Vitus' dance cured by metallotherapy. 
I refer to these facts without comment, for they are not yet sufficiently numer- 
ous to warrant us in drawing conclusions from them as to the utility of metallo- 
therapy, or even of zinc sulphate in chorea. 3 

Picrotoxine, which we have already seen used in epilepsy by Planat, has 

1 Kohn in his treatise cites ten cases of chorea treated successfully by bromide of 
potassium. He urges the importance of giving large doses, and he himself gives from one 
to two drachms a day. These doses, he thinks, have no injurious effect, (a) 

2 Vide Wad. Clinical Lectures on Chorea and its Treatment. (British Medical Jour- 
nal, 1827). Dr. Wad favors the large doses in chorea. Barlow, On the Treatment of 
Chorea by Zinc Sulph. (Medical Times and Gazette, 1857.) Butlin, Cases of Chorea 
Treated by Sulphate of Zinc. (Lancet, 1871.) West on Diseases of Children, article 
Chorea. 

3 It may be thought that the author, who is a recognized leader in therapeutics in the 
old world, is too much of a nihilist in treatment, and that he has rather summarily disposed 
of — as of little value — some of these medicaments, much employed in chorea. Certain it is 
that multitudes of practitioners all over this country, as well as elsewhere, are using brom- 
ides and zinc in this affection. It is always proper to ask the reasons for our cherished be- 



(a) Kohn, on the Treatment of Chorea by Bromide of Potassium in Large Doses, These de Paris, 1870. 
Gubler, Chorea Treated by Bromide of Potassium (Gaz. Hebd., 1865). Dumont, Chorea in a Pregnant 
Female Cured by Bromide of Potassium (Bull, de Ther. Feb., 1865). Gallard, Rheumatic Chorea Treated 
and Cured by Bromide of Potassium (Bull, et Mem. de Soc. Med. des Hop. de Paris, 1869). Worms, Intense 
Rheumatic Chorea Treated and Cured by Bromide of Potassim (Gaz. des Hop. 1869). Hough, Chorea of 
Thirty Years' Standing Cured in Six Weeks by Bromide of Potassium (Phil. Med. and Surg. Reporter, May, 
1869). Axenfeld and Huchard, Traite des Neuroses, Paris, 1882. 



ON THE TREATMENT OF CHOREA. 135 

also been tried in chorea; but these are trials which have not been repeated. I 
may say the same of nitrite of amyl, employed by Winfield-Ziegler. 4 

Electricity has been made use of under two forms, as galvanism and as 
galvanic baths. Remak and Onimus have recommended constant currents, ap- 
plied along the spine; these, which ought to be descending currents, according 
to Onimus, diminish sensibly the motor incoordination and the duration of the 
disease. 

Constantin Paul has eulogized the galvanic baths, which, if they do not 
give very positive results in chorea, seem at least to modify in a happy manner 
choreas of long standing, and choreic tremblings. You ought then to know 
how to give these baths, whose practical application is very simple. The elec- 
tric bath is composed of three parts; a bath-tub, a battery, and an electric coil. 
The bath-tub ought to be insulated, and should rest on glass legs, or its inner 
surface should have an enamel coating of glass or some other non-conductor. 
The battery consists of a single Bunsen cell; as for the helix, it is fur- 
nished with an interrupter and a graduator which enable you to increase or 
diminish the intensity of the current; it is constituted by a single wire sixty 
meters long and three millimetres in diameter. This is the way you manage 
this apparatus: The positive and negative poles of the battery communicate 
with the helix; then after having formed part of the coil, they terminate in two 
stops destined to receive the two other wires. These last terminate in the 
bathing-tub, the one at the foot, the other near the head; they end in two carbon 
plates which are fixed to the two extremities of the tub. The tub being well 
filled with water at a temperature of 35 to 37 C. (95 to 98 F.), the patient 
immerses himself in the water, with his back against the carbon plate where 
ends the negative pole, while his feet rest on the plate that represents the posi- 

liefs, and therefore it is proper to demand of those physicians who have the most faith in 
these remedies in chorea, if their faith is well grounded. 

The darkness in which the etiology of this disease is enshrouded ought to lead us to 
hesitate before we treat chorea as a neurosis whose essence is spinal excitation, pouring in 
the bromides till reflex excitability is well-nigh abolished and the blood is seriously impov- 
erished; this, too, in the case of a disease characterized by anaemia and debility. 

As for sulphate of zinc, when it does good in chorea, I am persuaded that it benefits 
not as a spinal medicament but as a general tonic, and hence deserves to be placed by the 
side of iron and arsenic. Nor do I believe in the large doses advised, despite the high au- 
thority of the late Dr. Thomas Watson. ( Vide Braithwaite's Retrospect, Part 80, page 54. 
Trans.) 

4 Winfield-Ziegler has employed nitrite of amyl in chorea, and has thus effected cessa- 
tion of movements after one or two weeks. This medicament is given by inhalation and 
the dose varies from three to ten drops, three times a day. The dose may be increased after 
several days; no harmful results have ever been observed. As for galvanic baths, Constan- 
tin Paul has applied them to the treatment of alcoholic trembling, of multiple sclerosis and 
chorea. In two cases of chorea he obtained in the one a rapid cure, in the other no result. 
These galvanic baths had a favorable effect on tremblings in general, from whatever 
cause, (a) 



(a) Winfield Ziegler, on the use of Nitrite of Amyl, especially in Chorea (Phil. Med. Times, July, 1876). 
Constantin Paul, in Bull, de Ther., t. 99, p. 193, on the Treatment of Tremblings and Other Troubles of 
Coordination of Movement by Galvanic Baths. 



136 ON THE TREATMENT OF CHOREA. 

tive pole. Then the current is regulated so that the patient supports without too 
much difficulty the successive discharges which result from the extra current. 
The baths have a variable duration of from fifteen to twenty minutes, and 
have a decided sedative effect on the choreic movements. 

I have dwelt at some length on these galvanic baths, because they have 
been of precious value to us, not only in relieving the trembling of chorea, but 
also those that accompany paralysis agitans and disseminated scleroses, and 
I have seen many practitioners fail in the attempt to give these baths 
properly. 

Beard and Rockwell have proposed a new method of employing electricity 
in these cases, which they call general electrization, and which resembles the 
method above described. The feet of the patient are placed on a moist copper 
plate, or he is made to sit on a wet sponge; this plate or this sponge is con- 
nected with one of the poles of a faradic battery, while the other pole is moved 
back and forth over different parts of the body. 

Lubelski was the first, in 1867, to advise the use of ether spray along the 
vertebral column. The pulverizations are made by means of a Richardson hand 
atomizer (or a Codman and Shurtleff spray-producer); the duration of the 
operation need not exceed five minutes. I have used this method of treatment 
(which is perfectly safe) with considerable benefit; certainly with diminution of 
the choreic movements. Zimberlin, Mazade, Jaccoud, Rose, Fabry and Mar- 
siglia have reported cases of chorea cured by the ether spray. 

The third class of medicaments applicable to the treatment of chorea is 
constituted by those remedies which produce sleep, and therefore cause cessa- 
tion of the choreic movements. In this group we place opium, chloral and 
chloroform. Before the introduction of chloral into therapeutics, great use was 
made of opium in large doses, and inhalations of chloroform. Trousseau, 
Benazet and others had advised opium in chorea, while Grey, Dacier and Pol- 
lock highly recommended inhalations of chloroform as a means of attenuating 
the intensity of the choreic manifestations. But these two medicaments have 
given place to a substance every way as active, and which produces the same 
effects without having the inconveniences of chloroform and opium, namely, 
chloral, which is admirably borne by children. 

Bouchut has given the most precise directions for the administration of 
chloral in chorea. He gives in the morning after breakfast forty grains of 
chloral in one dose, and so produces a sleep which lasts till noon; food is then 
administered, and forty grains more of chloral; then about tea-time, when the 
child wakes up, a full meal is given and generally the child goes to sleep again 
and sleeps all night long. In this way the young patient is kept asleep most of 
the time for several successive days. Cadet de Gassicourt employs another 
method. He prescribes every two hours a tablespoonful of a four-ounce solu- 
tion containing one dram of chloral, and continues the administration till deep 
sleep is produced. 

Whether you make use of the large dose of Bouchut, or the smaller doses 
of Cadet de Gassicourt, it is necessary always to administer the chloral in a con- 
siderable quantity of some diluent, and the best preparation is evidently that 



ON THE TREATMENT OF CHOREA. 137 

which consists in adding a proportion of syrup of chloral to a cup of egg and 
milk. [The syrup of chloral of the French Codex contains one gramme to the 
tablespoonful. — Trans.] 

Chloral can hardly be called a curative medicament, yet it renders great 
service when the disease attains considerable intensity, for it enables the patient 
during the sound sleep procured by this remedy to obtain cessation of the 
fatiguing and painful choreic movements. You ought then always to employ 
this remedy where you see the strength of your little patient becoming ex- 
hausted, and especially where you see the skin becoming excoriated by reason 
of the intensity of the muscular disorder. 

The last group of medicaments is composed of remedies which are 
addressed more particularly to the general condition, and here we have 
to study one kind of treatment which is debilitating, and another which is 
tonic. 

Debilitating medication is represented more especially by tartar emetic. 
Gillette is the most ardent defender of this kind of treatment, which has re- 
ceived a certain amount of favor, since we have seen Cadet de Gassicourt 
attribute to it a very beneficial influence in cases of grave chorea. These were 
Gillette's rules for the administration of this medicament: The first day hourly 
doses were given, till three grains were taken. The next day the dose was 
doubled; the third day it was tripled. Then the child was allowed to rest for 
three or four days, and if he did not get any better, the medicine was recom- 
menced in the dose of four grains the first day, eight grains the second, and 
twelve grains the third day. Then there was another interval of three or four 
days, and the medicine was renewed in doses of five grains the first day, ten 
grains the second, and so on. 

Whatever may be the value of the facts cited by Bouley, Gillette, Bonfils, 
Marcotte and Peslerbe, I am a most bitter opponent of this kind of treatment. 
I consider tartar emetic a very dangerous remedy, especially in the case of 
children. I expressed myself freely on this subject when lecturing on pneu- 
monia, 1 and am persuaded that under any circumstances it is impossible to find 
'in a hypothetical amelioration a sufficient compensation for the disorders 
which tartar emetic, administered in these large doses, determines in the 
digestive organs. 

Tonic medication, as in the case of all diseases which tend spontaneously 
toward recovery, occupies the first place in the treatment of chorea. At the 
head of the list of tonic remedies we must put arsenic, which is administered 
by mouth and by hypodermic injection. In this country it was Aran and his 
pupil Siredy who first showed the advantages of arsenic in the treatment of 
this neurosis. 2 

1 Vol. II. of Clinical Therapeutics. 

2 The arsenical medication is very much in vogue in France at the present day. Siredy 
employs the solution of Boudin, which contains a milligram of arsenic in each gramme, and 
of which this is the formula: 

1$ Arsenious acid, I gramme (15 grains). 

Water 1,000 grammes (about one quart). 



138 ON THE TREATMENT OF CHOREA. 

If you prefer to give it by mouth, you may make choice of Boudins' 
liquor (preferred by Siredy) of arseniate of soda, which Cadet de Gassicourt 
employs, or of Fowler's solution, and you may gradually increase the dose from 
one milligram to ten milligrams of arsenious acid per day; watching of course, 
the effects of the medicine on the digestive tube. I much prefer the hypoder- 
mic method, for this enables us to obtain the good effects of arsenic with quite 
small doses. Fowler's solution is marvelously adapted for subcutaneous injec- 
tion, for it occasions no irritation of the skin, or cellular tissue; you may boldly 
inject from one to four drops of the liquor potassae arsenitis, and you may 
even exceed this quantity. This mode of treatment by subcutaneous injec- 
tions, employed for the first time by Radcliffe in 1866, has been brought into 
general use by the school of Lyons, and Perraud and Garin have pointed out 
the advantages of this mode of treatment. 

By the side of the arsenical treatment we must place, almost in the same 
rank, the use of sulphur baths, hydrotherapy, and gymnastics. Hydrotherapy 
gives excellent results in chorea, and you ought always to resort to it when 
there is no cardiac complication. It is well to rely on the jet douche, the 
shower bath being of doubtful utility; you should, as Beni Barde 3 counsels, be- 
gin with the tempered douche, and accustom your patient by degrees to the 
cold douche. When the patient cannot have the benefit of an establishment 
for hydrotherapy it is well to rely much on wrappings in wet sheets. Sulphur 
baths are inferior to hydrotherapy in chorea; nevertheless in the rheumatismal 
forms it is a good mode of treatment. Finally, gymnastics, as Blache has 
shown, who out of one hundred and eighty-eight cases obtained by this method 
one hundred and two cures in thirty-nine days, is an excellent method of treat- 
ment; but the gymnastic exercises must be directed after a special manner, and 
Laisne has given the best rules for their performance. 

Laisne is one of those who have done the most to raise gymnastics to a 
practical art in its application, not only to the physical training and develop- 
ment of youth at schools, but also to our hospital service, as a therapeutic 
means. He several years ago instituted at the Hopital des Enfants, the 
gymnastic treatment of chorea, following the directions of Blache. It is neces- 
sary that the movements shall be rhythmical, and regulated by chanting ; some 
cases are speedily benefited, others not at all, by reason of the extreme inco- 
ordination, which will not allow the child to stand erect. There are, moreover, 
choreic children so impressionable that their disorder augments the moment 

M. Begin with ten grammes a day [ 3 ijss] of this solution, in the case of an adult, 
and increase by five grammes [ 3 j and gr. xv] each day till thirty or thirty-five grammes [an 
ounce and over] are taken daily. In a child you should begin with two grammes [ 3 ss] and 
increase by two grammes each day. Bouchut, Archambault and Cadet de Gassicourt em- 
ploy arseniate of soda; they begin with five milligrams and increase to twenty, twenty-five 
and thirty milligrams each day. Perraud employs subcutaneous injections of Fowler's solu- 
tion, in the dose of four or five drops once a day, or even once in two days. (Cadet de 
Gassicourt, Traite des Maladies des Enfants. Pomel on Arsenical Medication in Chorea. 
These de Paris, 1879), Garin on the treatment of chorea especially by arsenic, and hypoder- 
mic injections of Fowler's solution. These de Lyon, 1879. 

3 Beni Barde, Hydrotherapy, p. 645. Paris, 1874. 



ON THE TREATMENT OF CHOREA. 139 

that you endeavor to make them execute co-ordinated movements before 
spectators. 1 

In these cases (and here I partake of the opinion of Cadet de Gassicourt) 
gymnastics can have no good effect. You can aid these gymnastic exercises 
not a little by massage, which is especially applicable to the muscular groups 
the most affected by chorea. 

Such, gentlemen, are the therapeutic measures the most employed in 
chorea. It remains for me, in conclusion, to sum up the main points in the 
management of this affection. From a therapeutic point of view, you will 
divide the choreas into two groups: those which are relatively benign, and those 
which are relatively grave. 

In the case of the benign choreas (" St. Guy's dance ") which do not re- 
quire the patient to keep his bed, but allow him to walk about and perform 
certain movements, notwithstanding the motor incoordination, you should em- 
ploy, above all, gymnastics and hydrotherapy, and administer arsenic by mouth 
or hypodermically. 2 

If cardiac complications exist, you may apply a blister over the region of 
the heart ; you must eschew hydrotherapy, and be chary of gymnastics ; here 

1 Laisne trains choreic children in this way: The patient (supposing it to be a little 
girl) stands before the tutor, being held by his knees; the latter seizes her hands and requires 
her to make regular movements with each arm, counting, with loud voice or chanting, one, 
two, three, four, etc., with each movement. The child is told to listen, and to make no 
effort on her own account, for if encouraged too much to make voluntary efforts, her at- 
tempts would be likely to end in abrupt and disordered movements, which would defeat the 
object intended. Vigilance is required in these first manoeuvres, in order to be always ready to 
yield to the sudden spasmodic contraction of a member so likely to result in some children 
after these forced movements. The child is held as firmly as possible by the arm, and the 
endeavor is made to produce movements more or less rapid but always rhythmical with the 
legs. From time to time the child is allowed a brief rest ; finally the patient is placed with 
its back against a ladder, called orthopaedic ladder, and is made to grasp with its hands the 
rounds above the head ; the legs are supported while the child is kept suspended, as long as 
can be done without pain or fatigue ; after a little rest this manoeuvre is gone over again. 
During the intervals frictions are practiced of the extremities and other parts. The tutor 
must use the utmost judgment and patience and not demand more of the child than it has 
strength to perform. When a little improvement is noted and the child is getting wonted to 
its tasks, new gymnastics are attempted, and the little patient is now urged to use its powers 
of volition. Among these exercises we may enumerate the use of the dumb-bells, the arm- 
swing, the horizontal ladder, the parallel bars, etc. After a time the patient can control her 
movements sufficiently to go through these exercises without any assistance, engaging with 
her companions in these sports. 

In choreic persons who are bad cases, the exercises ought to be very frequent, as often 
indeed as twice a day. Caution must be taken that they do not injure themselves, and that 
sufficient intervals of rest are allowed. One is often obliged when patients are extended on 
a cot or long chair, to hold their arms and legs so that they may not injure themselves by 
the blows which they inflict, or may not slide off onto the ground. — Laisne, "On the Applica- 
tion of Gymnastics to the Treatment of Certain Diseases.") 

2 Probably no remedy is more used in this country in the treatment of chorea than 
arsenic. Fowler's solution is the form generally chosen ; beginning with three we gradually 
increase to eight or ten drops after each meal. The great majority of cases can be cured in 
from four to eight weeks by arsenic. Trans. 



140 ON THE TREATMENT OF CHOREA. 

massage and the ether spray along the vertebral column will do good. In the 
grave choreas, those which produce by reason of confinement in bed (neces- 
sitated by the extreme motor incoordination) excoriations of the skin ; and 
general troubles of nutrition, you may use chloral, bromide and massage. 
Chloral will enable you to procure sleep, and at the same time arrest of the 
choreic movements ; bromide of potassium will act in the same way, and the 
combination of these two medicaments makes an excellent sedative remedial 
agent. Massage methodically practiced will prove a powerful auxiliary, and 
you can complete your treatment by subcutaneous injections of Fowler's 
solution. But do not forget that the success of your medication depends more 
on the period in the evolution of the malady when you render assistance than on 
the medicines which you employ, and it is necessary when you are treating 
chorea, always to have in mind that you are dealing with a disease which 
regularly passes through definite periods, 1 and spontaneously tends toward 
restoration. Your treatment, then, should have for its end not to cause sudden 
cessation of the symptoms, which is impossible, but only to obtain a diminution 
in their intensity, and duration, and this is all that in the present state of thera- 
peutics one can hope to accomplish. 

Thus far we have been occupied only with neuroses; we now come to a 
more difficult subject, namely, the treatment of the ordinary affections of the 
cerebro-spinal axis, and I shall describe successively the therapeutics of menin- 
gitis, cerebral apoplexy, and myelitis. 

1 In accordance with this well-known law of spontaneous recovery, Gray and Tuckwell, 
(vide articles by these authorities in the Lancet for 1876, on the "Expectant Treatment of 
Chorea") advise expectancy in this disease and recommend only hygiene. Of twenty cases 
which came under their observation, the average duration was sixty-nine days, and these are 
the figures which Prof. See obtained in an analysis of the 117 cases. 



THE TREATMENT OF MENINGITIS. 

Summary. — Varieties of Meningitis — Tuberculous Meningitis — Its Curability — March of 
Tuberculous Meningitis — Symptoms — Prophylactic Treatment — Influence of Heredity — 
Hygienic Treatment — The General Treatment — Revulsion — Cold Applications — Blood 
Letting — Internal Treatment — Calomel — Quinine — Calmatives — Butternut Leaves — 
Iodide of Potassium — Difficulties of Diagnosis — Acute Meningitis — Chronic Meningitis. 

Gentlemen — This lecture will be devoted to the treatment of inflamma- 
tions of the meninges' with special reference to tuberculous meningitis. The 
latter is undoubtedly one of the most formidable diseases which you will ever 
be called upon to treat, and one of the most hopeless. 

Inflammation of the meninges may affect different points; sometimes the 

1 The cerebral membranes or meninges, are three in number, named as follows, begin- 
ning from without: dura mater, arachnoid and pia mater. A. Dura mater: This envelope 
presents for consideration, in the first place an external surface which adheres in certain 
places to the skull cap, the inside of which it lines. The adherent portions are of the nature 
of prolongations, the principal of which are ist, the external investments of the olfactory 
nerve (as far as the pituitary body); 2nd, the sheaths of the superior and inferior maxillary 
nerves (as far as the periosteum of the zygomatic fossa); 3rd, the sheaths of the facial and 
auditory nerves (as far as the bottom of the internal auditory foramen); 4th, the sheaths of 
the glossopharyngeal, pneumogastric and spinal accessory, nerves (as far as the foramen 
lacerum posterius); 5th, the sheath of the hypoglossal nerve; 6th, a reflection of this mem- 
brane upon the jugular vein. But the dura mater does not form the sheath of the optic 
nerve nor the periosteum of the orbit. From its internal surface smooth, polished, lined by 
the outer portion of the arachnoid, are given off, first the falx cerebri, which connects the 
crista galli and the coronal crest with the sides of the groove (superior arm of crucial ridge), 
of the occipital bone; second the tentorium cerebelli which separates the cerebrum from the 
cerebellum; third, the falx cerebelli; fourth, the pituitary fold. The dura mater is formed 
by fibres of laminated tissue inter-crossing each other without order. It is composed of a 
single layer, and the processes are duplicatures. Its arteries come from the internal carotid, 
the vertebral and the external carotid (pharyngeal branch). The veins empty into the 
sinuses. According to Sappy there are no lymphatics in this membrane. Its nerves are de- 
rived principally from the ophthalmic. B. Arachnoid : Of a tenacity which is very great and 
of greater transparence than the dura mater, this serous membrane presents for consideration 
two layers ; first a visceral layer, separated from the pia mater by the cerebro spinal liquid. Where 
it is in contact with it; a loose cellular tissue unites them. In passing over the various anfract- 
uosities, the visceral layer transforms the sulci into trigonal grooves, and forms towards the 
central parts of the base of the brain, veritable confluent cavities. The visceral layer, more- 
over, accompanies the sheaths which the dura mater furnishes to the nerves. Second, the 
parietal layer, a simple epithelial coat which, as we have said, lines the internal surface of the 
dura mater. Like all serous membranes the arachnoid constitutes a shut sack, and the two 
layers of which I have spoken are reciprocally continuous. This membrane is composed of 
a stratum of laminated tissue in which Marc See has noted the presence of elastic fibres and 
an epithelial covering; the first of these layers (the parietal) is extremely thin. The arachnoid 
contains no veins, arteries or nerves. C. Pia Mater : The most internal of the three cerebral 
membranes, it is constituted almost entirely of blood vessels. It is the nutrient membrane 
of the brain. It follows regularly all the undulations of the encephalon, whence it results 
that this membrane has more extensive relations with the cerebrum than either of the others; 

141 



142 ON THE TREATMENT OF MENINGITIS. 

membranes of the encephalon alone are inflamed, sometimes those of the 
spinal cord, sometimes both simultaneously, constituting cerebral, spinal, and 
cerebro-spinal meningitis, any one of which may be either acute or chronic. 

I can not here trace for you the pathological history of these different 
meningites, and, as in previous lectures, I shall devote myself to treatment, be- 
ginning with the inflammations of the meninges of the cerebrum, the tuber- 
culous form of which claims our first attention, by its frequence, its gravity, and 
its peculiar march, resulting as it does from the presence of tubercle granules in 
the encephalic envelopes. 2 

dipping down into the convolutions. It sends down into the interior of the brain a pro- 
longation called the choroid plexus. In relation by its external aspect with the cerebro 
spinal liquid, it furnishes investments to the nerves (neurilemma) which, differing from the 
membrane from which they arise, are more fibrous than vascular. By its internal aspect, it 
is in relation with the encephalon, to which it is united, by a great multitude of little blood- 
vessels. In structure the pia mater is constituted of connective tissue and blood vessels, es- 
pecially veins. Superiorly the connective tissue is in minimum quantity, but in the lower and 
posterior portions it predominates. It is to be remarked that in the pia mater the veins do 
not accompany the arteries and that the presence of lymphatics has not been detected; the 
nerves are chiefly from the carotid plexus. 

2 The disease described to-day under the name of tuberculous meningitis, and which the 
English and Germans often designate as an acute hydrocephalus, has long been the subject 
of observation, as is shown by the reports of Duverney (1701), Andre, of St. Clair (1732), of 
Paisley (1733), and the work of Sauvages (1763), which makes it a form of eclampsia. 
Several years later in 1768, Robert Whytt studied the disease, more thoroughly setting forth 
the symptoms and dividing it according to the character of the pulse into three periods. In 
his opinion (an opinion endorsed by other authorities, as Fothergill in 1771, Ludwigin 1774, 
Odier in 1779), the watery effusion into the ventricles, constitutes the disease in its entirety. 
According to other authorities coming after him, Quin in 1789, Goelis, Coindet 1807, Brachet, 
Du Chatelet, Senu and Martinet, etc., the immediate cause of the hydrocephalus is an in- 
flammation, but none of them described the veritable diathetic cause of the disease. With 
Guersant, the question enters into a new phase. Struck by the appearance of granules in 
the meninges, of tubercles in the lungs or other organs in children dying from acute hydro- 
cephalus, Guersant proposed to call the disease granular meningitis. The way was now 
opened, and soon appeared theses and memoirs affirming or demonstrating the tuberculous 
nature of these granulations. In 1830 Papavoine designated the disease under the name of 
tuberculous arachnitis. Then appeared the treatises of Rufz, Fabre and Constant, Gerhard 
Green, Piett, Becquerel, Barrier, Rilliet and Barthez, and Legendre which have sanctioned 
the name of tuberculous meningitis. In 1837 Lediberder discovered in the adult the same 
lesions as in the infant, and Valleix in 1838 published an important memoir on the tuber- 
culous meningitis of adults. Since this epoch numerous treatises have been published on 
the same subject, as may be seen from the bibliographic indications given below. Some 
physicians, even at the present day, repudiate the epithet of tuberculous and substitute that of 
granular. According to their view the granulations are not tubercles and consist only of 
fibro-plastic tissue; according to others there may be tuberculous granulations and granula- 
tions not tuberculous giving rise to the same symptoms, (a) 



(a) Coignet, Essay on the meningitis of infants. These de Paris 1837, Valleix, On the tuberculous meningitis 
of the adult 1838 t, Arch. Gen. de med); Becquerel, clinical researches on the meningitis of infants, 1838, and Note 
on a case of tuberculization of meninges in an adult 1846— Legendre. Study of the two forms of tubeiculous- 
meningo encephalitis 1846— Rilliet, On tuberculous meningitis in the infant (Gaz. Med., 1846)— Pivent, on tuber- 
culous meningo encephalitis, These de Paris 185-2, Bichet On simple and tubercular meningitis, These de Paris 
1852. Faivre On meningeal granulations. These de Paris 1853. Bouchut On dilatation of the veins of the 
retina and retinal hemorrhage in a case of tuberculous meningitis. Gaz. Med., 1865. Hayem, Study on the 
different forms of encephalitis, These de Paris 1868. Liouville, facts of tuberculous cerebro spinal meningitis. 
(Comptes de la Soc. de biol i86q). Archambault art meningitis in Diet encyclop. des sc med. 



ON THE TREATMENT OF MENINGITIS. 143 

From the special point of view with which we are concerned we have only 
to insist on these two points, the presence of tubercles, and the disorders which 
they occasion in the meninges and in the substance of the cerebrum, and ask 
ourselves if these lesions are curable and compatible with life. The curability 
of tuberculous meningitis is a question which has been much discussed of late 
years; it has been denied by some and asserted by others. The problem is a 
difficult one; it is so easy to confound the tuberculous phlegmasia in its acute 
manifestations with simple cerebral or fibro-purulent meningitis, which only 
differs from the other in the absence of the specific granulations. Moreover, 
there are certain convulsive phenomena, of reflex nature, which may simulate 
inflammatory meningeal troubles. These former affections being curable, it is 
easy to understand that, when a mistake in diagnosis has been made, and the 
supposed tuberculous child recovers, the medical attendant would naturally 
claim a demonstration of the curability of the disease under consideration. 

To-day this question is definitely decided, and the facts published by 
Archambault, Roger, Blache, Bonamy, etc., justify the affirmation that the evo- 
lution of tubercles and the accidents of phlegmasia developed thereby may be 
arrested in their march. The proofs are of two kinds, the one furnished by 
pathological anatomy, the other by ophthalmoscopic examination. 

As for the first class of proofs, we have the facts noted and reported by 
Roger, when a child recovers from a first attack of tuberculous meningitis to 
succumb to another, months or years afterward, and the autopsy reveals traces 
of the old phlegmasia and those of the new. As for the second class, you all 
know the importance of Bouchut's ophthalmoscopic studies in tubercular men- 
ingitis. The ocular examination with this instrument really enables us to make 
an autopsy before death by showing us the presence of tubercle granulations 
in the fundus oculi, so that, in an individual affected with meningitis, and pre- 
senting visible granulations in the choroid and retina, you may positively 
affirm the tuberculous nature of the meningeal inflammation; and, if the pa- 
tient gets well, you have evidence of the curability of the disease. It was 
precisely this that happened to me in the case of the hospital patient which I 
reported to the Societe des Hopitaux in 1878. 1 

This patient was a young man, twenty-three years of age, occupying No. 
21 of Ward St. Lazare. He had presented all the symptoms of tuberculous 
meningitis; his father, a drunkard, had died of phthisis; his mother had died 
of phthisis following diabetes, the examination of the fundus oculi by Dr. 
Meyer, one of our most competent oculists, revealed neuro-retinitis and tuber- 
cles in the choroid; my diagnosis certainly seemed to be well-founded. This 
young man, I assure you, recovered perfectly from his brain trouble, and for 
four months has not had a return of the disease. 

Moreover, why should tuberculosis of the meninges follow a different 
course from tuberculosis in other serous membranes? Do we not see tubercu- 
lous pleurisies get well? The remarkable investigations of Grancher have 
made clear the tendencies of tuberculosis in many instances toward recovery. 

1 Dujardin-Beaumetz, " Tubercular Meningitis; Arrest of the Disease; Recovery from 
all the Symptoms," Union med.," 1878. 



144 ON THE TREATMENT OF MENINGITIS. 

In others, however, the march is characterized by progressive fatal invasion. 
There is, then, gentlemen, no doubt of the possibility of the arrest of this dis- 
ease, even when the membranes of the brain have undergone inflammation; and 
this consoling idea ought to direct all your efforts in the treatment of this 
grave affection. Of course, the chances of cure are lessened as the disease 
advances. Possible at the onset, recovery is exceptional when, by reason of 
the presence of tubercle granules in the meninges, inflammatory disorders have 
arisen, entailing profound lesions in the encephalon. 

You know, in fact, that the pathological anatomy 1 of tuberculous menin- 
gitis shows us, besides the granules, hanging from branches of the Sylvian 
artery like clusters of grapes, all degrees of phlegmasia from simple thick- 
ening of the membranes to the production of pus. We also see ramollissement 

1 At the autopsy of a child that has died of tuberculous meningitis, you observe the 
following encephalic lesions. The dura mater does not ordinarily present any alteration, 
only the sinuses being gorged with blood. The arachnoid may be healthy, but it is generally 
dry, less transparent than ordinarily, somewhat opalescent, thickened, and covered with 
plastic exudation, and the alterations are especially marked at the base of the brain. 

The cavity of the arachnoid contains a small quantity of transparent or yellowish 
turbid serosity; the sub arachnoid tissue and the meshes of the pia-mater are infiltrated with 
a fibro purulent effusion of a yellowish, sometimes greenish, color, forming patches more or 
less extensive, especially abundant at the base of the brain, in the vicinity of the olfactory 
nerves, the fissure of Sylvius, whose borders they agglutinate, the optic commissure, and 
the blood-vessels at the base which this exudation surrounds as a sort of sheet. 

The pia-mater is injected throughout, or partially in the anfractuosities, or in the 
fissure of Sylvius; its veins are gorged with blood; it is thickened and intimately adherent 
to the brain, from which it can be removed only by taking with it a thin stratum of softened 
cerebral substance (the result of a hyperplastic encephalitis, according to Hayem). In the 
sub-arachnoid tissue and in the meshes of the pia mater, are found tubercle granulations 
which present themselves under the form of roundish corpuscles of variable size, white, 
opalescent, gray or yellow. Their number is variable also; sometimes few, scarcely visible, 
hardly appearing above the level of the surrounding tissue, difficult even to detect, at other 
times, they are dissemminated, forming a crop of small white spots or agglomerated in 
bunches like grapes. These granulations are met everywhere, but their favorite site is the 
base of the brain, along the fissure of Sylvius, over the cerebellum, the pons, the medulla 
oblongata, following the course of the blood vessels. They occupy the lymphatic sheaths of 
the vessels, and are produced by proliferation of the nuclei of the sheath and the adventi- 
tia of the arterioles of the pia mater; their presence provokes arteritis, the coagulation of 
blood in the vessels (thromboses), whence result foci of softening. The brain appears more 
voluminous; the convolutions are flattened and the superficial part presents a certain degree 
of ramollissement, and a punctiform redness. The ventricles are the seat of a constant 
effusion (from whence the name "acute hydrocephalus," given to the disease by the old au- 
thors); the quantity of liquid is variable and ordinarily oscilates between 60 and 100 grammes; 
its appearance is clear, limpid or turbid, opalescent, flocculent, containing debris of the ven- 
tricular membrane, or of the cerebral substance more or less softened. In the substance of 
the striate bodies, thalami or crura, there are sometimes spots of capillary softening, and of 
apoplexy, which are due, according to Rendu, to obliteration by thrombosis of arteries 
which terminate in these foci. On the part of the spinal cord similar lesions are observed, 
according to Liouville. As complications of granular meningitis we sometimes observe cer- 
ebral or meningeal hemorrhages, tubercles in different organs, the lungs, the glands, the 
mesentery, the intestine, the liver, the kidneys — on the part of the eye (Bouchut) pigmen- 
tary atrophy of the choroid and tubercles in the choroid. 



ON THE TREATMENT OF MENINGITIS, 145 

of the peripheral^ cortical strata, and finally that intraventricular exudation and 
that softening of the fornix which have long characterized this disease, to 
which the name of acute hydrocephalus was early applied. 

These different lesions have different symptoms, 1 and you know that, from 

1 The symptoms of meningitis have been divided into three periods. The first or pro- 
dromic period is characterized by troubles of the intelligence. The child is cross and 
peevish, his disposition shows a marked change; he may even become better natured; in the 
midst of his sports he is often dizzy; he complains of fatigue, and frequently has a desire to 
go to sleep. The digestive functions are performed poorly; there is want of appetite; some- 
times retchings and vomitings; obstinate constipation. This prodromic period is of variable 
duration. West fixes it at from four to five days, but it may be much longer, and for weeks 
and even months, digestive troubles and disturbances in the sphere of intellect may be 
noted, the attention of the physician and family being called thereto. In the second 
period the child keeps his bed; is in a stupor and does not readily reply to questions; 
the light disturbs him, and from time to time he utters plaintive cries; cries which have 
quite a peculiar character, and to which Coindet gave the name of hydrencephalic. Some- 
imes the headache is very severe, and the child does not cease to indicate with his hand the 
seat of suffering. The pulse is frequent, but very irregular, and the least fatigue increases 
it in a marked manner. The vomiting may cease at this period, but the constipation con- 
tinues and the abdomen takes that boat like form which characterizes meningitis. 

The third period is characterized principally by the appearance of convulsions and 
paralysis. The paralyses are partial and correspond to the points of the brain where are 
accumulated the tubercle granules or inflammatory products. Like the paralyses the con- 
vulsions are not general, they affect one side more than the other. To these periods of 
paralysis and convulsions succeed periods of coma, and nothing is more characteristic than 
the aspect of the infant at this moment; it seems like a figure of marble; the eyes are 
closed, the skin is cold and the appearance is that of a corpse. You scarcely see it breathe 
and there is nothing to indicate movement but the precipitate beating of the pulse. To this 
extreme pallor succeeds all at once an intense flushing of the face, the pulse becomes ener- 
getic and more frequent. The child utters plaintive cries, then relapses into the same state 
as before, and it is as much as ever that you are able to arouse him so as to obtain any reply 
to questions asked him. Then death occurs in convulsions or in the stage of coma. 

Apart from these periods the disease presents variable forms; we have first the 
typhoid form which has been more especially described by Legendre, and for a week or so 
it is very difficult to establish a diagnosis between meningitis and dothinenteritis; but at 
the end of this time the symptoms of the second and even the third period appear, and the 
diagnosis is easily made. Moreover the symptomatology of tuberculous meningitis is very 
variable, and it is difficult to give a description applicable to all cases, for the symptoms 
vary according to the parts of the brain affected. It is difficult to fix the duration of the 
disease; these are the indications which Barthez has laid down: 

ist. When the meningitis is preceded by regular prodromes it rarely lasts more than 
fifteen days, and ordinarily varies between fifteen and twenty days. 

2d. When it commences without prodromes in a sudden manner its duration is ordi- 
narily from twenty to thirty days. Sometimes it may even extend to forty-two days, or 
even two months. 

3d. When it develops in the course of confirmed phthisis its duration is very short, 
varying from three to eight days. 

Green has given the following statistics: 

31 patients died before 7th day. 

49 " " " 14th day. 

31 " " " 20th day. 

6 " " after 20th dav. 



3 46 ON THE TREATMENT OF MENINGITIS. 

the standpoint of semeiology, tuberculous meningitis has been divided into 
several periods, corresponding to the various anatomo-pathological phases of 
the malady. In the first periods we observe only the symptoms belonging to 
the evolution of tubercle granulations. In the latter stages we see unfolded 
the complex phenomena which result from the inflammatory alterations deter- 
mined in the brain and its membranes by the presence of the tubercles. 

All our therapeutic efforts, as must now be apparent to you, ought to be 
directed toward preventing the production of these inflammatory manifesta- 
tions, and whatever may be our chances of success in the initial periods of the 
disease, those chances will be well nigh nil in the terminal periods. it is suffi- 
cient to add that prophylactic treatment ought to occupy the first place. 

There is a fatal law which presides over the evolution of tubercles in 
different parts of the economy. I refer to the law of heredity, and tubercu- 
lous meningitis is no exception to this law. Therefore, we sometimes see all 
the children which spring from the union of tuberculous parents succumb suc- 
cessively to these first manifestations of tuberculosis, while the parents offer 
much longer resistance to the diathesis which they have transmitted to their 
offspring. Moreover, as there is a hereditary phthisis, an innate phthisis, and 
an acquired phthisis, so also it may be affirmed that there is a meningeal tuber- 
culosis corresponding to these three kinds of causes. If, as West has shown, 
in twenty-seven out of every forty-two cases of tuberculous meningitis this 
diathesis is found in the parentage, in other cases it is easy to trace the influ- 
ence of two other important factors — bad health of the parents on the one 
hand, and faulty hygienic training of the children on the other. 

The bad sanitary condition of the parents explains to us how alcoholism, 
diabetes, scrofula, excesses, cerebral troubles, disproportion in the ages of 
father and mother, etc., may be invoked as causes of tuberculous meningitis in 
the offspring. But we must also give due credit to bad hygienic con- 
ditions of the children. In our infant wards we find every day a striking con- 
firmation of what I have just said. When in a little child we have diagnosti- 
cated miliary granulations of the meninges, we always observe, as determining 
causes, either tuberculosis or alcoholic excesses in father or mother, or, on the 
part of the child, an infancy passed amid the most deplorable hygienic sur- 
roundings. Hence indications are plain enough from the point of view of 
prophylactic treatment. 

In all families where you have the occasion to apprehend the appearance 
of meningeal granulations, either because one of the children has already fallen 
a victim to the disease, or because the parental antecedents lead you to fear an 
outbreak of the kind, you ought to insist upon the utmost care in the rearing 
and education of the child. The tuberculous mother must not nurse her own 
infant; the child should, if possible, be brought up in the country and kept 
much in the open air; prolonged and fatiguing intellectual tasks must be 
strictly forbidden. By gymnastic exercises you should endeavor to establish a 
just equilibrium between the muscular functions and those of the cerebro- 
spinal axis. By hydrotherapy you may calm the cerebral excitement of these 
young children, who almost always display a precocious intelligence. You 



ON THE TREATMENT OF MENINGITIS. 147 

should have a careful supervision of the food, and be ready to oppose the least 
disorder of the digestive organs, for here, as in the evolution of pulmonary 
tuberculosis, it is the failure of nutrition in general which predisposes to 
cerebral granulations. 

You should, then, have a surveillance of all the periods of early life, with 
these two ends in view: to favor in every way the nutritive functions, and to 
avert excitation of the cerebro-spinal axis. I have said early life, for if the 
tuberculous brain affection oftener attacks children in the first years of their 
life (from three to six), it also finds its victims among youths between the ages 
of fifteen and twenty years. 

But, unfortunately, you are not often called till the advanced periods of the 
disease, when the meningeal inflammation has commenced its ravages. The 
prodromal periods have passed unnoticed, and the guardians of the child have 
placed to the account of peevish disposition, or to irritation of the digestive 
organs, the changed character of the child, the constipation, the vomiting, etc. 
When you are called in, meningitis is pronounced. What are you going to do? 
The treatment is the same whether the meningitis be tuberculous or simple. 

The revulsive medication has been employed in all its rigor, and just as 
pleuritic, peritoneal, pericardial, articular inflammations have been treated by 
vesicatories, so also blisters have been applied to the shaved head of the hydro- 
cephalic child. This revulsive treatment has been varied, and irritant inunctions 
have been advised with tartar emetic, or with croton oil ; the actual cautery has 
been recommended, and even the moxa. 1 These revulsive measures have been 
applied in all their rigor, not only to the shaved head, but also to different 
parts of the body, and in particular to the inner aspect of the thigh. Without 
absolutely denying the good effects of the revulsive medication in meningitis, it 
must be admitted that this method of treatment has been abused, and, for my 
part, I have more than once seen the condition of the patient rather aggravated 

1 Hahn, of Aix la Chapelle, has vaunted the efficacy of strong tartar emetic ointment in 
the treatment of meningitis. He discards all internal treatment, shaves the head and rubs 
in the stibian ointment every two hours. Henrietti, of Brussels, prefers inunctions with 
croton oil, and Turner, of Edinburgh, and Watson, of Southampton, commend this prac- 
tice. Trucy, of Marseilles, has reported cases of recovery by the use of the actual cautery. 
Mongenot and Nysten have returned to the moxa and the cautery in the treatment of 
meningitis in the Hopital des Enfants. Smith in his treatise on hydrocephalus recommends 
rubbing into the scalp of the sinciput two hours at a time, a caustic pomade which excites 
violent derivation. Durr, of Hall, applies to the shaved head of the child a caustic plaster 
size of a two franc piece, consisting of tartar emetic and blistering cerate; this is kept on 
from four to six hours till the epidermis is raised when another dressing is applied of the 
same ointment, after which the vesicated surface is dressed with an irritant ointment. 
Bellaige reports the case of a child three years old, affected with meningitis, which was 
cured by an issue of caustic potash on the top of the head, (a) 



{a) Hahn: On he efficacy of tartar emetic ointment in tuberculous meningitis (Bull, de Ther. t. xxxvii., 
p. 54). Henrietti: On the treatment of acute meningitis by croton oil, rubbed well into the shaved scalp 
(Presse Md. Beige, Dec. 1857). Turner: On the treatment of meningeal inflammations by frictions of croton 
oil (Edinb. Md. Jour. Nov. 1868). Constant: On the emply of cauteries and moxas in the treatment of 
meningitis and encepholstis (Bull, de Ther. 1835 t. ix p. 303). Bellaige: Concerning the meningitis of in- 
fants, and its treatment by caustic issues on the top of the head (Bull, de Ther. 1838 t. xv., p. 181). 



148 ON THE TREATMENT OF MENINGITIS. 

than benefited by the irritation and pain provoked by severe vesication in this 
disease. 

Therefore I warn you to be chary in the employment of these violent 
measures, and to prefer the constant application of ice to the head, which 
seems to me to have quite as much influence as the most energetic revulsion. 
If you resort to the ice-cap, it should be made to cover the whole head, and its 
application should be continuous. You may also make use of cold affusions to 
the head, as Schutzenberger 1 advises, and, better -still, the apparatus recom- 
mended by Dumontpellier, whereby a constant current of cold water is main- 
tained. The head should previously be shaved. To complete what I have 
said as to local treatment, it has been advised to leech the patient behind the 
ears; some, as Torci, have gone farther, and have proposed, not only bleeding 
from the temporal veins, but even abstraction of blood directly from the 
longitudinal sinus. [Torci opened this sinus from the anterior fontanelle, and 
withdrew eight ounces of blood. The child, a nursing infant, singularly enough, 
recovered, but nearly a month afterward succumbed to a second attack.] For 
my part, I am opposed to these emissions of blood in meningitis, and particu- 
larly in tuberculous meningitis; they weaken the child, without any sufficient 
compensatory advantage. 

The internal treatment of meningitis comprises a great number of medica- 
ments; unhappily, the very fact that the number is so great indicates how 
inefficacious, often, they all are. These medicaments may be ranged in several 
groups; some are directed to the phlegmasia, some to the symptoms which it 
produces, others especially to the tuberculous cause of the affection. Menin- 
gitis, considered as a simple inflammation, has been combated by the ordinary 
antiphlogistic treatment. Mercurials, and especially calomel, have been advised 
in small and often-repeated doses. This practice has received the sanction of 
Trousseau, and at one time hardly a child was attacked with meningitis that 
was not mercurialized to salivation. At the present day the calomel treatment 
is much in vogue, but the mercurial is given in fractional doses. A grain of 
calomel is rubbed up with a drachm of white sugar, and divided into ten 
powders; of these, one powder is given every hour. Unfortunately, it is not 
proved that the mercurial medication of meningitis which is really tuberculous 
has ever done any good, and it is probable that the success which has been 
claimed for this treatment is attributable to faulty diagnosis — I mean to say, 
that it is probable that the meningitis was of syphilitic rather than of tubercu- 
lous nature. That an inflammation of the meninges due to syphilitic neoplasms 
might be benefited by a course of mercurials, there can be little doubt. The 
good results which have been ascribed to quinine in meningitis are probably 
explicable on the supposition of errors in diagnosis. There are, in fact, two 
affections whose symptoms are almost identical with those of meningitis: such 
are, attacks of pernicious fever of the cerebral form, and typhoid fever in infants. 
In the first class of cases quinine has a marvelously happy effect. I have even 

1 Schutzenberger advises to place the child's head over a bucket at the edge of the bed, 
and to play upon it streams of water from a watering-pot ("Des affusions froides dans 
'lhydrocephalie aigiie." 



ON THE TREATMENT OF MENINGITIS. 149 

known children, given up to die from tuberculous meningitis, to get well under 
quinine, for their brain disease was simply the cerebral congestion of malignant 
remittent fever. These facts ought to be well impressed on your minds, and, 
whenever you have reason to suspect the toxaemic influence of malaria, you 
should hasten to give quinine, and as the stomach is often irritable, you may 
have to administer the quinine in suppositories, or in the form of hypodermic 
injections of the bromhydrate. 

The same remarks are applicable to typhoid fever, and recently Barthez 
has called attention to this point, and recommended that whenever, in the case 
of a young child, you are in doubt as to whether you ought to call the disease 
meningitis or typhoid fever, you should give very large doses of quinine, say a 
scruple in four doses (which may advantageously be administered in coffee). 
If marked, amelioration follows this medication, you may, with good reason, 
suspect the disease to be typhoid fever, and not meningitis. 

There is a second group of medicaments addressed to the nervous symp- 
toms developed by the meningeal inflammation. To calm the delirium, the 
agitation, and the convulsions which occur at different periods of the disease 
opiates have been given ; but chloral and bromide are especially to be recom- 
mended. Chloral, in combination with bromide, is here as useful as we found 
it to be in whooping cough ; if it does not cure, it alleviates. In cases where 
cures are reported from this treatment, it is more than probable that the disease 
was not meningitis, but the eclampsia of childhood, dependent on peripheral or 
toxaemic and not on central lesions. 

Two medicaments have been prescribed, from empirical considerations, in 
this affection — the extract of walnut-leaves and iodide of potassium. 

Luton, of Reims, was the first to vaunt the curative efficacy of the extract 
of the leaves of walnut (known as extract of Grandval); this medicament was 
directed to the tuberculous cachexia, and not to the inflammation. Luton 
seems to have had some little success, but no one at the present day has any 
confidence in this treatment. 

It is not so with iodide of potassium. Experimented with first by Blache, 
then by Bourrouse, and lauded by Bonamy, iodide of potassium counts many 
earnest advocates. In fact, I think that, considering the testimonials in its 
favor, and the perfect safety of this medicine, it is well always to have recourse 
in hydrocephalus to the iodide, of which as much as two grammes ( 3 ss.) may 
be given to children daily in divided doses. 1 It is possible that the cases where 
this treatment does good are of syphilitic character, and that it is ineffective in 
real tuberculous meningitis. I am unprepared to decide this difficult question. 

You see, gentlemen, that, notwithstanding the premises which I laid down 
at the beginning of my lecture relative to the curability of tuberculous menin- 
gitis, I am obliged to admit that we have no certain curative means, and, unhap- 
pily, when we see little patients get well whom we have treated for this malady, 



1 The formula of Burrouse, of Lafiore, is as follows : 1$ Iodide of potassium, five 
grammes ; water, sixty grammes. M. A teaspoonful every three, four, or five hours, well 
diluted. Never exceed two grammes a day ("Moniteur des sciences med.," June, 1861). 



150 ON THE TREATMENT OF MENINGITIS. 

we are in doubt whether the recovery is not rather the result of an error in 
diagnosis than of anything which we have done. 

Therefore, these two facts — the possibility of the resorption of the inflam- 
matory and tuberculous products, or the possibility that you have mistaken for a 
malignant tuberculous one that is benign and curable — should encourage your 
efforts in the treatment of this formidable disease. 

Moreover, even in tuberculous hydrocephalus you will often observe marked 
remissions which are misleading, and ought always to keep you on the watch- 
After passing through the most severe phases of the disease, after the delirium, 
convulsions, and coma, one sees the child suddenly revive, intelligence comes 
back, the convulsions cease, and the family are ready to exclaim that a miracle 
has been wrought. Unhappily, this treacherous remission is short ; the cere- 
bral symptoms return, and the fatal event soon comes. 

Among the various affections which may be confounded with tuberculous 
meningitis 1 there is none more deserving of mention, because more common — 

1 Tuberculous meningitis, described for the first time in a complete manner by Whytt 
under the name of dropsy of the ventricles of the brain, and designated also at the present 
day under the name of acute hydrocephalus, has its maximum of frequency in children from 
2 to 7 years of age, and in adults from 20 to 30. It is often hereditary, being derived from 
parents who have had tuberculous affections or cerebral disorders. It is, indeed, not an un- 
common event to see the children of perfectly healthy parents succumb at an early age to 
tuberculous meningitis. The disease may begin suddenly ; it is generally, however, pre- 
ceded by a prodromic period of greater or less duration. The child complains of frequent 
headaches, and of being weary ; there is a notable change in the character as before re- 
marked. The child ceases to take any interest in its sports or studies. There is loss of 
appetite, occasional vomiting and emaciation. There are frequent remissions followed 
by exacerbation. The headache becomes more violent, vomiting comes on during 
fasting or after meals, and at the same time there are fever fits. At this period of the incep- 
tion of the disease, one often observes some inequality of the pupils, intermittent strabis- 
mus, slight convulsion of the facial muscles, grinding of the teeth during the night in the 
midst of a troubled sleep ; some children manifest a sort of periodical lameness in their 
walk. Little by little the malady progresses, the symptoms are more pronounced (period of 
cerebral excitation); the headache is more exasperating, with occasional remissions, the vom- 
iting of greenish and glairy mucosites occurs more frequently when the stomach is empty; 
the constipation is obstinate. The little patient becomes more and more fretful, refuses to 
play, and insists on keeping its bed, where it lies stretched out on its back, with closed eyes, 
wrinkled brows and anxious expression, avoiding the light and the sight of brilliant objects, 
which seem to increase the headache. It remains in a stupor, and replies to questions in 
monosyllables, and angrily resists any attempts on the part of the physician to examine into 
the condition. 

Hydrocephalic children dream frightful dreams, mutter to themselves, are often heard 
to moan, and frequently carry their hand to their heads with the exclamation, " My head, 
oh, my head !" At other times they utter mournful cries (hydrencephalic cries), which are 
characteristic. The night is more disturbed than the day, the pulse more accelerated, above 
100, the skin is hot and dry. The delirium is often less calm, and you will observe grinding 
of the teeth, winking of the eyelids, alternation of redness, and pallor of the face, inequal- 
ity of the pupils and diplopia. The opthalmoscopic examination, when it can be made, 
shows peripapillary congestion, dilatation of the vessels of the retina, and papillary deform- 
ity, (Bouchut). Then at the end of several days the infant complains less than before, no 
longer turns away his eyes from the light, vomits rarely, or does not vomit at all. The 
pulse, which was accelerated, is slower, falls to 90, 80, 60, 50, and even 40, and becomes 



ON THE TREATMENT OF MENINGITIS. 151 

attacking as it does both adults and children — than simple acute meningitis. 
This disease, within certain limits, is curable ; astiologically, of course, it is dis- 
tinguished from the strumous meningeal inflammation by the absence of tubercle 
granulations. 2 For this simple meningitis the treatment is the same as for the 
tuberculous ; you should especially insist on cold applications, revulsives, and 
calmatives. But in this form of meningitis our success will depend on the 
degree of the inflammation and the extent of the lesions. In respect to this 
latter point, the brain is sometimes strangely tolerant. We now and then see 
tumors of considerable size develop in the interior of the cerebrum, or even at 
its periphery, with a latency such that scarcely any symptoms reveal their pres- 

irregular. At the same time the temperature falls from ito i^ degrees. As with the pulse, 
the respiration presents inequalities and irregularities ; to a deep sighing respiration svc- 
ceeds at times an interval of rest, a long suspension of breathing. It seems as though the 
patient forgot to breathe for a few moments, then he makes several rapid inspirations, and 
the same respiratory phenomenon is reproduced. The belly becomes flattened, is retracted, 
is hollowed out (boat belly). If you pass the finger over the abdomen marking out traces on 
the skin, you cause red lines to appear (meningitic spots or rays), to which Trousseau at- 
tached an exaggerated importance. One also observes convulsive movements in the limbs, 
grimaces, a working of the lower jaw, gnashing of the teeth during sleep, fugacious and 
partial contractures of the different muscles, (muscles of the neck, hand, forearm, leg, foot); 
there is at times tetanic stiffness of the muscles of the nucha. After an attack of convul- 
sions it is not rare to find one side paralyzed completely or incompletely. Like the contrac- 
tures, the paralyses are either temporary or permanent. The temporary paralyses almost 
always succeed convulsions ; they may disappear more or less quickly or change to the 
other side. The permanent paralyses are due to spots of softening in the striate bodies or 
cerebral peduncles, or to compression of the base of the brain and cranial nerves by the 
meningeal exudation. One of the most frequent paralyses is that of the third pair ; next in 
frequency comes paralysis of the muscles of the face, of the eye (strabismus), of the arms, 
and of the inferior extremities. After an attack of convulsions, or gradually, as a result of 
the disease, the infant falls into a state of drowsiness and coma, from which it cannot be 
aroused. It lies on its back, one leg extended, the other bent on the abdomen, much of the 
time motionless, face of waxy paleness. The eyes are closed or else opened wide, the eye- 
ball has a constant movement of rotation, pupils are dilated, unequal, sluggish, and often 
half hid under the upper lid. 

The pulse increases in frequency, 140 to 180 ; it is never so frequent as the day of 
death ; the temperature rises to 104 or 105 F. Retention of urine is observed towards the 
close of life. An abundant and viscous sweat covers the emaciated body of the infant, res- 
piration is embarrassed, and the patient succumbs to the progress of asphyxia, unless carried 
off by a convulsion. 

2 The diagnosis of tuberculous meningitis, easy in many cases, is often beset with dif- 
ficulties. The practitioner will be guided in his investigation by the mode of invasion, 
ordinarily slow and insidious, the vomiting of pultaceous biliary matters, the obstinate con- 
stipation, and the irregularities of the pulse and respiration. 

Simple acute meningitis, cerebrospinal meningitis, the eruptive fevers, may lead him 
astray for a moment, but these diseases generally present very marked points of difference 
from the disease under consideration. In acute meningitis the disease manifests itself sud- 
denly in the midst of health, the fever is high, the cephalalgia is severe, the attacks of vom- 
iting near together, the phenomena of excitation more accentuated, the delirium at times 
is very early, being noisy and even furious. 

In cerebro spinal meningitis the debut is also sudden. The delirium, the contractures, 
and all the disturbances of sensibility are early. Moreover, the patients complain of pain 



152 ON THE TREATMENT OF MENINGITIS. 

ence. On the other hand, we frequently observe, from the moment that the 
cerebral cortex is effected, even if the lesion be quite circumscribed and of 
little depth, the most pronounced disorders in the sphere of intellect or motility 
owing to irritation of the nerve-cells of the peripheral strata. It is for this rea- 
son that these meningeal inflammations are accompanied by grave symptoms, 
even when the phlegmasia is not extensive. 

The greater part of mental disorders which are grouped under the general 
name insanity are only chronic meningites, and the mental disturbances, so 
numerous and so similar, which alcohol produces, result from the pachymenin- 
gitis which the presence of alcohol determines in the cerebral envelopes. I can 
not enter into the treatment of these chronic meningites — treatment little under- 
stood, and which belongs to the domain of the expert in mental diseases rather 
than that of the ordinary practitioner. 

I must, before concluding, speak of the treatment of infantile convulsions. 
It is an interesting subject not yet well elucidated, for the convulsions of infancy 
are only symptoms, which may be produced by a variety of causes. They may 
depend on inflammation of the brain or its membranes, or on certain condi- 
tions of dyscrasia (uraemia, for instance), and belong to the group of eclamp- 
sias, or else they are simply reflex manifestations, generally of little gravity, 
which appear in the course of various affections, as dentition and diarrhoea. 

In eclamptic convulsions, or in those which have for their point of depart- 
ure reflex action, the best mode of treatment consists in the internal administra- 
tion of bromide of potassium, or chloral, or in inhalations of chloroform or 

along the spine, increased by pressure and by movements. The invasion of the eruptive 
fevers is also sudden, and there is a high febrile temperature. At the onset of scarlet fever, 
measles and small-pox, you observe vomiting and sometimes delirium, but soon after symp- 
toms appear which point to the true disease. In these fevers, moreover, as in simple acute 
meningitis, and cerebro spinal meningitis, you have not the obstinate constipation, the 
retraction of the belly, the irregularities of the pulse and respiration. 

Like tuberculous meningitis, typhoid fever and gastro-intestinal irritation {embarras 
gastrique), often have an insidious commencement. But if typhoid fever, particularly the 
ataxic form, may lead into error, you soon note characteristic symptoms, which remove all 
doubt: epistaxis, rose-colored lenticular spots, meteorism, the increasing march of temper- 
ature, the frequency of the pulse, etc ; there is, besides, absence of vomiting. More- 
over, you will remember that if you have the care of a young child, that typhoid fever is very 
rare under five years, while meningitis is frequent. 

In embarras gastrique there is vomiting, constipation, headache ; but the disease appears 
in a time of full health, the tongue is coated and not moist, as in meningitis, the pulse is 
regular, and under the influence of treatment — a purgative, for instance — the constipation 
ceases along with the cephalalgia. 

Intestinal worms, by their presence, sometimes provoke divers nervous troubles ; there 
may be inequality of the pupils, vomitings, even convulsions, with slowing and irregularity 
of the pulse. You apprehend meningitis, but if there be headache, it is slight, the constipa- 
tion does not continue, and the symptoms all disappear with the administration of a vermi- 
fuge. 

Ophthalmoscopic examination ought to be made when possible. According to Bouchut, 
in 75 per cent, one observes important alterations on the part of the optic nerve and retina, 
such as neuro-retinitis, peripapillary cedema, phlebo retinal thrombosis, tubercles of the 
choroid, etc. 



ON THE TREATMENT OF MENINGITIS. 153 

ether. All medicaments which ansemiate the brain seem to do good in these 
cases ; it is from this consideration that Trousseau proposed compression of the 
carotids. I warn you to be chary in the use of revulsives — such as sinapisms 
and blisters — in these cases, for severe cutaneous gangrenes, more difficult to 
cure than the convulsions themselves, have more than once been produced by 
the prolonged action of even a mustard cataplasm, and this in consequence of 
the insensibility which results from the fit. 



THE TREATMENT OF APOPLEXY. 

Summary. — Apoplexy — Definition — Causes — Apoplexy by Rupture -Apoplexy by Anaemia 
— Apoplexy by Congestion — Treatment of Apoplexy by Haemorrhage — Treatment 
before the Attack — Treatment of the Attack — On Blood Letting — Its Role — Inefficacy 
of Blood Letting — Treatment after the Attack — Pharmaceutical Means — Arnica — 
Strychnine — Electricity — Treatment of Apoplexy by Anaemia — Before, During, After 
the Attack — Treatment of Apoplexy by Congestion — The Apoplectic Temperament 
— Pathogeny of Cerebral Hyperaemia — Hygienic Treatment — Bad Influence of the 
Alcohols — Obesity and Apoplexy — Utility of a Normal Functional Condition of the 
Digestive Tube — Constipation — Purgatives — Aloes — Haemorrhoids in Apoplectic 
Patients — Diagnosis — Conclusions. 

Gentlemen — To devote a lecture to the treatment of apoplexy may seem 
to some of you -useless, or even behind the times. This old word, apoplexy, 
to-day well-nigh obsolete, belongs rather to tradition than to clinical medicine; 
nevertheless, I persist in my resolution, and I will tell you why. If by reason 
of the progress of pathological anatomy we are able to know the pathogeny of 
the various cerebral apoplexies, and follow step by step the haemorrhage from 
the production of the miliary aneurism to the rupture of the same, and even the 
necrobiotic alterations of the encephalon determined by emboli or thrombi, we 
are unfortunately unable in the living subject to establish a clear distinction 
between the effects of haemorrhage and those of migrating or autochthonous 
clots, which give rise to symptoms so similar, although the causes are so dis- 
similar. 1 

Between the apoplectic attack resulting from haemorrhage into the cere- 
brum, and that resulting from cerebral anaemia, there exist, from a clinical 
point of view, shades of difference but slightly marked, and save in exceptional 
cases, we are reduced, in making our diagnosis, to conjectures; conjectures 
which are often falsified by the post mortem examination. As this apoplectic 
ictus has been the subject of numerous discussions which have deeply concerned 
therapeutics, it has seemed to me desirable to retain the word, and to set forth 
the treatment, which is likely to give you the best results. But before going 
farther, let us come to an understanding about the signification of the word 
apoplexy. 

That sudden suspension of cerebral action, complete or incomplete, per- 
sistent or transient, which characterizes apoplexy, 2 has had different interpreta- 

1 Recamier has established the following diagnostic signs: 

In the case of haemorrhage: Contracture of the paralyzed members, diminution of 
sensibility in the paralyzed parts, alteration of the intelligence. 

In the case of ramollissement: Complete resolution of the paralyzed members, con- 
servation and augmentation of sensibility, conservation of intelligence. 

2 Apoplexy, known from the most remote antiquity, described by Hippocrates, Galen, 
Celsus, Paul of Egina, Bcerhaave, etc., called siderato, morbus attonitus, attonitus stupor, etc., 

154 



THE TREATMENT OF APOPLEXY. 155 

tions according to the prevailing medical doctrines. Under the domination of 
the doctrines of Hippocrates and Galen, the cause of the apoplectic phenomena 
was ascribed to sudden arrest of the vital spirits, or even to the presence of 
pituitous humor in the ventricles of the brain. But from the commencement of 
the seventeenth century the progress of pathological anatomy demonstrated 
that it was rupture of blood vessels which, in the majority of cases, caused the 
apoplectic stroke, and Morgagni brought clearly to light the preponderating 
importance of cerebral haemorrhages. At the same time, authorities, while 
admitting the frequency of haemorrhage in the pathogeny of cerebral apoplexy, 
did not, at the end of the last century, consider that as the sole cause, and while 
granting sanguineous apoplexies, they also affirmed the existence of serous 
apoplexies, and even certain essential apoplexies, called apoplexies sine materia. 
But from the beginning of this century, and especially since the work of 
Rochoux in 1814, apoplexy was regarded as nothing but the manifestation of 
cerebral haemorrhage or congestion, and the notion of essential apoplexy was 
given up. The study of circulatory disturbances, and especially of the vascular 
changes produced by embolism, soon modified the exclusive view of Rochoux, 
and to apoplexy by rupture of blood vessels was now added apoplexy by embol- 
ism, or by cerebral anaemia. Therefore, I shall adopt with some modification 
the definition given by Schiitzenberger, and shall call cerebral apoplexy the 



is constituted by an assemblage of cerebral phenomena, characterized by sadden loss of 
consciousness, with resolution or paralysis of the members, without arrest of the circulation 
or respiration. 

It has been considered as the effect of the arrest of the circulation of the vital spirits in 
the veins, arrest of the vital force, repletion of the ventricles by a pituitous humor (Hippo- 
crates, Galen), arrest of the sensitive or motor spirits (Avicenna), obstruction of the vessels 
by phlegm or atrabile; it is due to relaxation of the nerves, spasm of the meninges, (obso- 
lete views). 

In more recent times, by reason of anatomical examinations, apoplexy has been 
referred to compression of the brain and nerves by dilatation of the blood vessels, by effusion 
of blood or serum, etc. 

Morgagni, Hoffmann, ascribe the principal cause to cerebral haemorrhage; Hoffmann, 
at the same time, recognizes two forms: 

Sanguineous apoplexy and pituitous apoplexy. 

According to Rochoux and his pupils, apoplexy becomes the synonym of cerebral 
haemorrhage, and for a long time this view has been adopted, and even now many authorities 
are of the same opinion as Rochoux, considering apoplexy as the equivalent of haemorrhage, 
whether cerebral, medullary or pulmonary, etc. 

This is to give an erroneous sense to the word apoplexy; as in the first place, all 
cerebral haemorrhages are not accompanied by apoplexy, and the apoplectic ictus has been 
noted in many other maladies without the occurrence of cerebral haemorrhage. The phe- 
nomena of apoplexy may manifest themselves in cases of effusion of serum in the ventricles 
(serous apoplexy); in other cases no appreciable encephalic lesion is found, as in apoplexies 
called nervous, the essential apoplexies (sine materia); the patients fall as if suddenly smitten 
down, just as in cases of epilepsy, or of eclampsia, and at the same time there is no cerebral 
haemorrhage. 

As has been seen, apoplexy may arise from many causes, and clinically, it must be 
considered only as a symptom; it is the expression of a cerebral perturbation, of a sudden 
suspension, temporary or permanent, of certain functions of the brain. 



156 THE TREATMENT OF APOPLEXY. 

sudden suspension of cerebral action, produced by an internal cause affecting 
the circulation (vascular rupture, congestion or anaemia) acting directly on the 
encephalon. 

I shall not enter here into the description of the symptoms of apoplexy, 
for which I refer you to your text-books, 1 but shall discuss the proper methods 
of treating this disease, unfortunately so common, giving reasons for such thera- 
peutic hints as I shall offer But in order to understand the bases of our 
therapeutic endeavors, it is necessary that we should examine, as rapidly as 
possible, the pathogeny of the disease in accordance with the above definition. 



1 Cerebral apoplexy is rarely ushered in by prodromes; when these exist they consist in 
headache, vertigo, dazzling sensations, muscae volitantes, tinnitus aurium, formications, 
numbness; at times there is weakening of the memory, hesitation of the speech, etc.; often 
the invasion of the disease is sudden. 

The patient is taken with vertigo, sensations of flashes of light; he makes several stag- 
gering steps, then falls suddenly, deprived of consciousness, of power of movement, of sensi- 
bility; he is in a state of complete resolution, but the beatings of the heart and the respiratory 
movements continue. The pulse is full, strong, regular; the breathing is painful, often 
embarrassed and stertorous; the face is often congested, the features drawn to one side; at 
each expiration the muscles of the cheeks and lips are puffed out; the eyes are turned to one 
side, like the head, and towards the sound side (conjugated-deviation of the head); the pupils 
contract under the influence of light, unless the hemorrhage affects the tubercular quadri- 
gemina, the corpora geniculata or the optic commissure. 

The patient is not always completely insensible; he groans in a characteristic manner 
when one pinches him; moreover, on lifting up the two limbs, lower or upper, it is observed 
that if one falls heavily and passively, the other falls less suddenly and its descent seems re- 
tarded by an instinctive, unconscious muscular contraction. 

Often there are at the moment of the attack or a little after, involuntary evacuations of 
urine or fecal matters. Sometimes death is quite sudden, but this is quite rare; there is no 
such thing as fulminating apoplexy (apoplexie foudroyante), except in bulbar haemorrhages. 
Generally in the apoplectic form of cerebral haemorrhage, however considerable may be the 
loss of blood, the patients live several hours, sometimes days, and succumb either to the 
progress of the initial haemorrhage or to the asphyxia brought on by the respiratory dis- 
orders. 

In other patients one sees, at the end of a certain number of hours, consciousness gradu- 
ally return, and the patient wakes out of his stupor, but he is hemiplegic, and the paralysis 
is seated on the side opposite to the lesion, i. e., on the right side, when the hemorrhage is 
on the left, and vice versa. 

With the paralysis there is sometimes anaesthesia more or less extensive; taste and 
smell are more or less altered. The hemiplegia is partial or total. 

With respect to the face, the paralysis is often seated on the same side as that of the 
limbs, or it may be crossed and seated on the opposite side (crossed or alternate hemiplegia). 
One side of the face and of the forehead is immobile, without expression; the mouth is dis- 
torted, and the commissure of the lips is drawn in the direction of the sound side. At each 
expiration the cheeks are seen to be puffed out; the patient can neither blow nor whistle. 
The point of the tongue when projected from the mouth is often turned towards the paralyzed 
side, and sometimes does not seem to be touched by the paralysis. The speech of the 
patient is generally broken and confused. 

The limbs are often unequally paralyzed; the arm is the most so. At first the tempera- 
ture is higher on the paralyzed side; later the equlibrium seems to be restored; unless there 
be atrophy, in which case the temperature seems to be more elevated on the sound side. 

The muscles of the pharynx, as well as all other muscles concerned in deglutition are 



THE TREATMENT OF APOPLEXY. 157 

Cerebral apoplexy is the result of three great factors: congestion, more or less 
intense, of the brain; sudden arrest of the blood destined to nourish a more or 
less extensive department of the encephalon, or, lastly, rupture of one of the 
blood vessels supplying a region of the brain; the latter constituting what used 
to be called sanguineous apoplexy. Once these affections were pathologically 
classed in the group of haemorrhages, and supplementary, congestive, dyscrasic 
apoplexies were described. To-day we can expunge all these divisions, thanks 
to the discovery of miliary aneurisms made by Bouchard and Charcot. These 
pathologists have pointed out this capital fact, that rupture of the cerebral ves- 
sels is always preceded by the alteration of the walls of those vessels, veritable 
aneurisms, and that it is the rupture of these aneurismal portions which causes 
irruption of blood into the mass of nervous tissue, and all the consequent 
symptomatic and anatomo-pathological disorders which characterize the intra- 
cranial hemorrhage. 2 

paralyzed. Troubles in micturition and defecation are also frequent (retention, sometimes 
incontinence of urine and fecal matters). 

The muscles of the abdomen and of the thorax do not, as a rule, participate in the 
paralysis. 

Hemiplegia may supervene without any apoplectic stroke; it comes on during the 
waking hours and developes more or less rapidly; the patient, in full possession of his con- 
sciousness, has a little vertigo, observes flashes of light before him, then complains of formi- 
cation and numbness and sees the paralysis gain, in whole or in part, one half of the body; 
at other times, having gone to bed well, he wakes out of sleep hemiplegic, without having 
lost consciousness and without having had any troubles of the intellect. 

The duration of the hemiplegia is variable; sometimes it disappears after several days, 
weeks or months. Some patients even get completely well. In other cases we note the 
development of contracture of the paralyzed muscles, first of the lips, then of the leg, the 
flexors being affected rather than the extensors. There is at the same time atrophy of the 
limbs. 

The hemiplegia does not often go away completely, and it may remain stationary in- 
definitely. When recovery takes place, movement reappears first in the leg, then in the arm, 
and restitution may be permanent. But in other cases, and especially when three weeks 
after the attack one notes exaltation of the tendinous reflexes, atrophy of the limbs is seen 
gradually to supervene, contractures of the paralyzed muscles and especially the flexor 
muscles, the extensors being rarely affected. 

When the patients do not succumb to the progress of the central hemorrhage or as the 
result of a new attack, they are carried off, either by a consecutive cerebral affection, or by 
an intercurrent disease (such as pneumonia), or by the exhaustion consequent on the eschars, 
which so often form over the sacrum or trochanters in hemiplegic patients, (a) 

2 These aneurisms are undoubtedly the most frequent causes of cerebral haemorrhages, 
especially in the haemorrhagic apoplexies of old age. Charcot and Bouchard found them in 
foyers and in the ochreous cicatrices of ancient haemorrhages, in the convolutions, corpora 
striata, optic thalami, and the pons. Visible to the naked eye, they appear in the form of 



(a) Todd, Clinical Lectures on Paralysis, London, 1856. Grisolle, Pathologie interne. Monneret, Pathologie 
interne. Hardy and Behier, Pathologie interne. Durand Fardel, Traite" Clinique des Maladies des Viellards, 
1854. Rokitanski, Lehrbuch der Fatherlogischens Anatomie, 1856. Gendrin, Traite Philosphique de Medi- 
cine Pratique, 1838. Rochoux, Recherches sur 1' apoplexie, 1814. Bennet, Pathological and Histological 
Researches on Inflammation of the Nerve Centres. Paget, on Fatty Degeneration of the Small Blood-vessels 
of the Brain, and its Relation to Apoplexy, London Medical Gazette, t. x. 6, 1850). Bouchard, Recherches 
sur la Pathologenie des Hemorrhagies Cerebrales, 1866. 



158 THE TREATMENT OF APOPLEXY. 

Apoplexy by ansemia or necrobiosis, produces the same effects as sanguine- 
ous effusion, but by a mechanism altogether different. It occasions sudden 
cessation of the functions and death of a more or less circumscribed region of 
the brain, by reason of the arrest of the arterial circulation. We have here 
something comparable to the local gangrenes which accompany the ligature of 
the arteries of limbs, and this comparison is, moreover, so exact, that you know 
that the ligature of the carotid very often gives rise to an attack of apoplexy, 
with resulting hemiplegia of the opposite side. 

This sudden stopping of the circulation in one of the arteries or arterioles 
of the brain, may have one or two origins: either it results from an alteration 
in leco of the arterial twig; chronic endarteritis of the vessel causing an autoch- 
thonous clot to be formed, which completely obliterates the lumen of the vessel: 
or else the vessel is sound, while the clot that obstructs it comes from a more or 
less distant point of the arterial system, or from the heart itself, being an em- 
bolus. 

Between these two states, apoplexy from effusion of blood, and apoplexy 
from necrobiosis, or ansemia, is placed another group of apoplexies thus far 
badly defined, and which result from sudden and intense congestion of the 
brain, congestive apoplexy, or coup de sang. It is easily understood how an 

little globular granules, whose diameter varies from two-tenths of a millimetre to one milli- 
metre, and even more. They have a violaceous color, more or less deep, if the wall of the 
blood-vessel is thin, and the blood liquid*; reddish brown or ochreous, or even black, if the 
blood is concrete; bluish or brownish, if the parietes are thickened by proliferation of the 
connective tissue elements of the adventitious membrane. 

They are met with everywhere, but especially in the convolutions, either on the surface 
or at the point of reunion of the cortical and medullary substance, and at the same time in 
the pons, and great basal ganglia. 

The number of these aneurisms is very variable; from one or two to a hundred or 
more. 

Bouchard believes that these aneurisms (which are seldom or never seen before the age 
of sixty) are only the concomitant of an alteration of the blood vessels much more general, a 
sort of arterial sclerosis analogous to that which Rokitanski describes under the name of 
chronic periarteritis, but differing essentially from simple atheromatous and fatty degen. 
eration. This vascular change affecting the entire arterial system of the encephalon, is 
especially conspicuous in the smaller intra-cerebral arteries, although the large trunks of the 
meninges and at the base of the brain may be pervaded by the same alteration, an alteration 
which consists in an exaggerated and often enormous multiplication of germinal elements in 
the interstices of the arterial trunks, and in the lymphatic sheath, and in atrophy of the mus- 
cular tissue. At the same time there is general dilatation of the vessel, with constrictions at 
various points where the circular fibres remain intact. In fine, we meet with abrupt dilata- 
tions in arteries thus modified, veritable aneurisms, whose rupture produces cerebral hemor- 
rhage. 

In the opinion of Charcot and Bouchard, the principal lesion in cerebral hemorrhage is 
peri-arteritis, or external sclerosis, while in the case of ramollisement, the lesion is endarter- 
itis, or internal sclerosis. Zenker mentions an opposite view: that the lesion always com- 
mences by alterations of the adventitia. (a) 



(a) (Cruveilhier, Anatomie. Pathologique— Bouchard and Charcot. Nouvelles Recherches sur la Patho. 
genie de l'hemorrhagiecerebrale, Arch, de Phys. 1868, p. no — Bouchard, de la Pathogenie des hemorrhagies. 
These de Paris, 1869— Liouville, des anevrysmes miliares, Th. de Paris, 1871.) 



THE TREATMENT OF APOPLEXY. 159 

afflux of blood, in great quantity, to the encephalon, or sudden stasis in the 
intra-cranial vessels, gives origin to a sudden but temporary arrest of the cere- 
bral functions. 

Having once these divisions well in mind, let us see how we can intelligently 
act when we have to deal with apoplexy from any one of these causes. I am 
assuming that we are in a condition to diagnosticate the particular lesion, a 
matter which I told you before is often involved in great difficulty. 

As for cerebral haemorrhages we are to take into consideration prophylaxis 
and the treatment during and after the haemorrhage. 

The role of prophylactic treatment is to prevent the production of these 
alterations of the walls of arteries which result in miliary aneurisms. It would 
seem that we are well nigh impotent in this regard. It is as much as ever if 
we can anticipate these aneurisms by heredity, and according to the laws which 
Dieulafoy has established, which go to show that the greater part of cases of 
cerebral haemorrhage are witnessed in persons belonging to the same family. 

In the majority of instances these miliary aneurisms do not reveal themselves 
by any symptoms, and their rupture is the first indication which we have of 
their existence. The most that we can do, in persons predisposed, in order to 
avoid the rupture of these aneurisms, is to make use of all those hygienic and 
medicinal means, which moderate the cerebral circulation; but I shall have 
more to say on this point when I come to speak of apoplexy from congestion. 

The vascular wall gives way, the blood invades the cerebral mass, the pa- 
tient has what is termed "a shock," he looses consciousness and becomes hemi- 
plegic; you are called in haste; what are you to do ? Twenty years ago the 
response would have been forthcoming; you would have made haste to take 
your lancet and bled the patient freely. This was one of the rules of thera- 
peutics concerning which there was little or no variance of opinion. 

Since the time of Aretaeus, Paul of JEgina, Ccelius Aurelianus, Avicenna, 
Baglivi, down to Rochoux, Bouillaud, Monneret, Valleix, Grisolle, etc., the 
whole world was agreed that bleeding (or rather bleedings) was the proper way 
to treat apoplexy from blood effusion, and it was as much as ever if any exten- 
uation of this procedure was granted in the case of anaemic and debilitated 
subjects. 1 The divers indications were pointed out for general bleeding, and 

1 In ancient practice, as soon as the patient has had an apoplectic shock, he was bled 
on the spot, and this was considered the only proper treatment. Blood letting was divided 
into general, derivative, and revulsive. 

General blood letting was practiced from the arm, the jugular vein or the saphena. It 
was a subject of debate whether they should take blood from the sound side or the paralyzed 
side. 

Aretaeus used to bleed from the sound side. Baglivi from the paralyzed side. 

Valsalva recommended to take blood from the jugular vein, but it was soon recognized 
that bleeding from this vein was dangerous practice. 

Chauffard preferred the saphena, claiming that derivation from this vein has a revulsive 
as well as a spoliatory action. 

The number of general blood lettings was often considerable; it was directed to continue 
them till the pulse was no longer hard and bounding. 

Derivative blood letting. — This consists in the application of wet cups and leeches to the 



160 THE TREATMENT OF APOPLEXY. 

for derivative and revulsive bleeding. It was a matter of serious discussion 
whether it were preferable to practice phlebotomy in the jugular, as Valsalva 
taught, or in the saphenous, as Chauffard advised, or even in the pituitary 
membrane, rather than at the end of the elbow, as Cruveilhier had proposed. 
One bleeding was not enough; you must bleed several times; at the same time 
Rochoux advised not to bleed more than four times in the generality of cases. 
They also discussed whether it were not better to bleed the paralyzed side than 
the sound side. Finally, they even went farther, and Bell, Nyemann, Zuliani 
and Gatherwood, taking their stand on hydraulic principles, more or less dis- 
putable, substituted arteriotomy of the temporal arteries for phlebotomy. 
Claudius Barbier, of Lyons, went ahead of all his contemporaries and prede- 
cessors in this practice; comparing the cranium to a tight cask, he advised that 
when the vein was to be opened the skull should be trephined. 2 

To-day, knowing better the mechanism of apoplexy, we ought to repudiate 
this kind of treatment, because nothing goes to show that we can at once arrest 
the haemorrhage which results from rupture of some blood vessel, and to accom- 
plish this result by bleeding, you would have to bleed the patient to syncope, a 
very dangerous procedure. Moreover, who is the physician that would now think 
of checking haemorrhage from a small artery by blood letting ? So then blood- 
letting is not to be thought of in the apoplectic seizure, for it is useless, and 
may be dangerous. It cannot prevent the consequences which result from rup- 

occiput or to the angle of the jaws. As many as twenty leeches would be placed over 
the tract of the jugulars; these were repeated two or three times after general bleeding. 
(Monneret.) 

Cruveilhier advised to bleed from the pituitary vein, and for this purpose he used a 
special instrument which he invented. 

Revulsive blood letting. — This consists in the application of leeches to different parts of 
the body, more or less distant from the seat of the haemorrhage, as the malleoli, the thighs, 
anus, etc. 

Attempts have been made to formulate the application of blood letting in apoplexy. 
Hints were obtained from the state of the pulse. When the pulse was full but intermittent, 
it was necessary, according to Shauffer, to refrain from blood letting. The same precaution 
was necessary in the case of feeble old men. VanSwieten cautions against bleeding in grave 
cases, for, he says, if the patient dies after the blood letting, the physician would be blamed 
for his death. 

It was generally admitted that in haemorrhages which seemed to accompany active 
cerebral congestion bleeding was especially indicated, as being palliative and pre- 
servative, (a) 

2 Sir Charles Bell believed that arteriotomy was preferable to phlebotomy in the case 
of extravasation of blood in the brain; reasoning from doubtful hydraulic principles, he 
thought that the former operation diminished, while the latter increased the afflux of blood 
to the brain. Barbier would even bore a hole in the cranium, by means of a simple drill, to 
avail himself of atmospheric pressure in depleting the brain. (Bell — The Different Effects 
of Arteriotomy and Phlebotomy in Apoplexy — British Medical Journal, January, 1843. 
Barbier — A New Mode of Treating Apoplexy — Jour, des Conn. Med., Juillet, 1843. 



(a) Aretseus, De curatione apoplexise. Chauffard, Des avail tages de la saigne revulsive dans la 
plupart des maladies de la tete. (Arch. G6n. de Med., Mars, 1832, p. 2871.) Monneret et Fleury, Compendium 
de Medecine Pratique, t. 1 p. 278. Cruveilhier, Diet, de MeVl. et de Chir. Pratiques, t. in, p. 255. 



THE TREATMENT OF APOPLEXY. 161 

ture of the miliary aneurisms; it weakens the patient; places him in conditions 
of hydraemia and anaemia which oppose the clotting of the blood in the rup- 
tured vessels and the obliteration of those vessels, and on this very account 
favors new haemorrhages. It is plain then that we are impotent at the moment 
of the attack to combat the effects of the rupture of the cerebral arteries, and 
that our role consists in attending to symptoms as they arise. Observe if the 
alvine evacuations are free, if the functions of the bladder are regularly per- 
formed, place the patient in the best hygienic conditions possible. 

Either the haemorrhage is considerable and will prove fatal, or has affected 
only a limited part of the encephalon; the ensuing paralysis, then, is sharply 
defined, and, according to the extent of the haemorrhagic foyer, it gradually dis- 
appears. In cases of this kind we may do much to prevent the inflammatory 
phenomena which accompany the disorders produced by the presence of the 
clot in the brain, and also to hasten the resorption of the clot. 

To fulfill the first indication blood-lettings may do us some service. Much 
as I am opposed to this spoliative treatment at the moment of the attack, I am 
quite prepared to recognize its utility in the case of encephalitis. So, whenever 
after an apopleptic seizure, you note the appearance of fever and the other 
symptoms which characterize inflammation of the cerebral substance, you ought 
to apply leeches over the mastoid processes, or even take blood from the arm. 

You may also apply ice to the head. Lallemand thinks that cold applica- 
tions may do good during the attack itself. I do not agree with him, and 
believe that the only benefit which you can derive from this means is obtained 
in the inflammatory stage which succeeds the haemorrhage. 

In order to avert new haemorrhages, and with this end in view, to combat 
congestive tendencies, drastic purgatives are indicated. It has been advised 
to give iodide of potassium on the ground that this medicament in small doses 
has the property of diminishing congestion of the encephalon; on data, more 
theoretical than practical, is also based the employment of ergot of rye in such 
cases. 

As for the paralysis, consequent on destruction of cerebral tissue, it de- 
creases in the ratio of absorption of the products of the hemorrhage. Many 
measures have been counselled to hasten the return of muscular movement. 
vSome have proposed massage and stimulating frictions; others, from purely 
empirical considerations, certain medicaments, such as arnica; others still, in 
accordance with more exact physiological data, have proposed the use of strych- 
nia and electricity. 

I will say but little of frictions and massage, and I see little that is disad- 
vantageous in the employment of these means, except it may be the danger of 
provoking traumatism of the paralyzed parts, already the seat of trophic disturb- 
ances often sufficiently intense to cause phlegmons and gangrene. As for arnica 
and all stimulating medicines, such as melissa, mentha, and lavender, they do 
not play any active part. It only remains to consider strychnia and electricity. 

Strychnia was especially employed by Magendie and by Bradsley. It was 
hoped that the contractions determined by this medicament would hasten the 
return of muscular movements. You should be very careful in the employ of 



162 THE TREATMENT OF APOPLEXY. 

strychnia in hemiplegia, for this alkaloid produces congestion of the cerebro- 
spinal axis; a congestion always injurious when the patient is suffering from the 
effects of cerebral hemorrhage.* On the whole, it is better to rely on elec- 
tricity. 

Electricity accomplishes two purposes; it opposes the trophic disturbances 
which accompany haemorrhages into the brain, and above all it combats the 
consecutive alterations in nerves which find their central termination in the part 
of the brain which has been destroyed. Bouchard has described for us the 
march of these secondary scleroses, which engender persistent disorders in the 
paralyzed parts. You can employ here the galvanic current, or the faradic cur- 
rent. When you wish particularly to influence the nutrition of paralyzed parts, 
you employ galvanism; when you wish to provoke muscular contraction and 
prevent atrophy in paralyed muscles you use faradisation. But you should 
exercise great caution in the use of electricity and not resort to this therapeutic 
agent till all the congestive or inflammatory symptoms have disappeared. 
Electricity, when too long applied (or in too strong currents) induces in the 
corresponding parts of the brain an excitation more injurious than useful. 

In the case of apoplexy from embolism or thrombosis, we can do little in 
the way of prophylaxis before the attack. It is necessary to avoid all circum- 
stances which favor the production of an embolus in the left heart and in the 
arterial system, or those alterations of the encephalic vessels which give origin 
to autochthonous clots. Here, however, we are well-nigh powerless. When 
the apoplectic seizure has taken place, and a clot has caused obstruction of an 
important bloodvessel, inducing necrobiosis of the part of the encephalon sup- 
plied with its nutrient blood by that vessel, our role is still an impotent one, 
We cannot by any therapeutic measure re-establish the interrupted circulation, 
and we are just as powerless to hasten resorption of the necrosed parts. As 
you see, then, when we are concerned with cerebral necrobiosis, we can only be 
spectators of the disorders produced without the ability by modes of treatment, 
more or less energetic, to arrest the evil at its commencement or modify its 
evolution. 

It remains to consider apoplexy due to cerebral congestion. Here we can 
accomplish much more, and we can in a measure successfully oppose cerebral 
hyperemia. It is to this group of apoplexies that we have seen applied the 
name apoplectic temperament or constitution. You know the description that 
has been given of typical cases; you have heard described the flushed counte- 
nance, the injected eyes, the short, thick, massy neck and large shoulders of 
apoplectic subjects who experience under the influence of slight excitements 
bursts of heat and flashes which bespeak the imminence of dangerous cerebral 
congestions. 

[*In American practice, strychnia is much given in hemiplegia, but with most physi- 
cians, more from routine, and from some vague idea that it may be useful to arouse dormant 
motor power than from any experience of its utility. If given, it should be given very 
cautiously and in a commencing dose not exceeding one-twentieth of a grain. The dose may 
be gradually increased till some jerking or tension is felt in the paralyzed muscles. (Vide 
Stille, Therapeutics, vol. 2, p. 155.) A good form is the liquor strychniae; dose five to ten 
drops. Trans.] 



THE TREATMENT OF APOPLEXY. 163 

There are a great number of affections of which cerebral hyperaemia is a 
symptom. The description above given applies to arthritic patients with con- 
gestive tendencies, to individuals affected with mitral diseases, to certain 
emphysematous subjects, in all of which cases you will observe the congestive 
or apoplectic facies above set forth. Cerebral hyperaemia arises from a great 
number of causes, and the treatment ought to vary according to the affection 
of which it is an expression. 

Already when treating of diseases of the heart I told you what you ought 
to do to combat congestive cerebral tendencies, and I need only remind you that 
the most of the therapeutic measures which have been proposed for apoplexy 
are directed not to the haemorrhage, but to the hyperemia, and this is the end of 
both hygiene and prophylaxis. A long time ago Lancisi showed the importance 
of hygienic therapeutics in these cases, and your attention ought to be directed 
principally to these two points: diet on the one part, and regularity of the 
bowels on the other. 

As for diet you ought rigidly to proscribe all those aliments and all those 
beverages which are likely to induce cerebral excitation. Your patients must 
abjure altogether wines, generous liquors, in fact alcohols in general, which have 
a doubly deleterious action in apoplexy, for they not only produce hyperaemia 
of the brain, but they also engender alterations of the blood vessels, the result 
of which is rupture of those vessels or obturation. You should caution your 
patient not to use too highly-seasoned food, and should put him on a regime 
consisting principally of white meats and fresh legumes and other vegetables; 
fatty and feculent matter should be excluded, and, in short, everything which 
can augment the production of fat in the economy. 

Do not forget that the hyperaemia, and the apoplectic tendencies which are 
its consequences, are often connected with obesity. Polysarca in hindering the 
play of the diaphragm, and especially in opposing the regular functionating of 
the heart by fatty accumulation around that organ, and by the alteration of 
the heart muscles which attends it, almost constantly, gives rise to hyperaemia 
of the brain; and it is for this reason that the hygienic treatment of obesity is 
quite applicable to congestive apoplexy. Therefore, you should establish by 
daily exercise a relation always exact between nutrition and combustion, and 
you should combat by appropriate means all the symptoms produced by 
slackened nutrition. 

You should also endeavor to promote a healthy state of the digestive tube. 
Constipation ought to be avoided at any cost, and you ought always to keep up a 
certain state of diarrhoea in these congestive and plethoric patients. Here the 
purgative mineral waters are indicated — Pullna, Freiderichshall, Hunyadi Janos, 
Ems, Sprudel. Here you may give aloes with excellent effect, which, besides 
unloading the intestines, causes congestion of the rectum and produces 
haemorrhoids. A great many apoplectic patients have piles, and these latter act 
as safety valves to the head, both by reason of the congestion which they de- 
termine in the region of the anus and the fluxes of which they are the seat. 

The alkaline waters 1 are good in these cases, not because they anaemiate 

1 Carriere has proposed the internal use of alkaline medicines as a rational treatment 



164 THE TREATMENT OF APOPLEXY. 

the patient, but because they regulate nutrition. 2 You should watch the urine 
of your patient, for many apoplectics are gouty, and you ought always to keep 
the urinary secretion abundant. 

As a pharmaceutical means, besides purgatives and diuretics which are 
always of some utility, you may make use of arsenic, iodide of potassium and 
aconite. The latter diminishes in a notable manner cerebral congestion. 
Dry and wet cups, leeches, and sometimes even venesection may be valuable 
auxiliaries. With regard to venesection: much as lam opposed to blood-letting 
in the period of haemorrhage, I am convinced that in cases of great hyperaemia 
of the brain, with flushing and lividity of the countenance, blood-letting may 
temporarily do some good. 

Such are the therapeutic rules applicable to the three varieties of apoplexy 
to which I have called your attention. Our treatment would be more accurate 
and scientific were we always able to distinguish the one from the other of these 
three varieties. Unhappily this is not an easy matter. 3 If we can generally 
diagnosticate cerebral hyperaemia, it is really impossible to distinguish haemor- 

in cases of predisposition to apoplexy. He employs the bicarbonate of soda, of which he 
gives nearly two drachms a day. But when there is apoplectic congestion, he replaces the 
bicarbonate of soda by ammonia, giving from five to ten drops of the spirits every hour, (a) 

2 Picquot in Bull, de Ther. t. 61 lxi., p. 321, has advised the arsenical treatment as 
prophylaxis. This is the formula: 

R Arceniate of Potash i 00.05 

Tinct . Aconite 10 . 00 

Tinct. Digitalis 5 . 00 

Distilled water 300.00 

M. Dose, a tablespoonful morning and evening in half a tumbler of sweetened water 
two hours before meals. 

3 The diagnosis of cerebral haemorrhage is sometimes attended with difficulty, by reason 
of the number of diseases which may present similar symptoms at the commencement; 
apoplectic and hemiplegic symptoms. Meningeal haemorrhage, cerebral congestion, acute 
ramollissment, saturnine and uraemic encephalopathies and pernicious fever with comatose 
symptoms may be accompanied with apoplexy. In uraemia and pernicious fever the study 
of the temperature will help to clear up the diagnosis; in the commencement of the haemor- 
rhage the temperature is lower than natural, then it goes on increasing till the fatal termina- 
tion; in pernicious fever, the central temperature is always superior to the normal; in uraemia, 
with comatose symptoms, there is a progressive lowering of the central temperature. 

In cerebral congestion the diagnosis is determined by the march of the disease; at the 
end of a variable period, all the morbid symptoms disappear. 

Syncope, asphyxia, alcoholic intoxication may lead into error. But in syncope, the 
suspension of respiration and circulation; in asphyxia, the respiratory troubles; in alcoholic 
intoxication, the odor from the breath, will serve to clear up the diagnosis. 

In intraventricular haemorrhages, or in those which take place in the substance of the 
pons, there are often convulsive seizures simulating epilepsy; the aspect of the patient, the 
tongue which presents fissures or cicatrices, the dilatation of the pupils, the temperature and 
then the march of the disease will remove all doubts. It is the same for certain apoplexies 
which are only attacks of epilepsy and to which Trousseau called attention. 

The diagnosis of meningeal haemorrhage is more difficult: according to Boudet, this 



(a) Carriere, on the rational treatment of cerebral congestion and of apoplexy by alkalies and in partic 
ular by bicarbonate of soda. Paris, 1854. 



THE TREATMENT OF APOPLEXY. 165 

rhagic apoplexy from apoplexy by anaemia, and we can only make hypotheses 
and conjectures when we come to actual experience at the bedside. This very 
circumstance should lead us to be chary with regard to any active treatment 
during or after the apoplectic seizure. Better always to do nothing than to do 
harm. 

In my next and final chapter, I shall consider the treatment of spinal 
myelitis. 

kind of apoplexy is likely to be attended with contracture as an initial symptom. In the 
ordinary form of hsemorrhagic apoplexy, contracture is a late symptom. 

Chronic ramollissement is distinguished from cerebral haemorrhage by its march. 
During its progress it is accompanied by cephalalgia, vertigo, intellectual enfeeblement, 
numbness which is habitual, and sometimes by contractures. 

More difficult is the diagnosis of acute ramollissement. The debut may be apoplecti- 
form, and without prodromes. At the same time the loss of consciousness is apt to be more 
transient and less complete in ramollissement. Moreover, in ramollissement by embolism, 
lesions may often be noted in other organs, which, produced by the same cause, shed light on 
the diagnosis (pulmonary apoplexy, infarctus of the spleen, hematuria, etc.) After the 
attack the hemiplegia is alike in both diseases, and it is almost impossible to distinguish 
them. You must be guided by the evolution of the disease. 

In softening, and especially senile softening, from endarteritis, the symptoms often 
present oscillations; the paralysis is less complete at certain hours of the day. Aphasia is a 
symptom less common in apoplexy from haemorrhage than in ramollissement. 

According to Charcot, conservation of consciousness with sudden invasion, belongs 
rather to ramollissement; variable hemiplegia belongs to it exclusively, and aphasia almost 
exclusively. 

Haemorrhage often coincides with hypertrophy of the heart and Bright's disease. 
Cerebral ramollissement by embolus occurs in the same patients, and accompanies visceral 
infarctus. 

Ramollissement by thrombosis is seen especially in individuals who are a prey to 
tuberculous or cancerous cachexia. Ramollissement by senile endartitis is frequently accom- 
panied by atheromatous degeneration of the arteries of the extremities. 



ON THE TREATMENT OF CHRONIC MYELITES. 

Summary. — On Diseases of the Spinal Cord— Progress of Pathological Anatomy — The 
Different Inflammatory Processes — Myelites, Acute or Parenchymatous — Myelites, 
Sclerous and Interstitial — Their Varieties — General Treatment — Blood-letting, Local 
and General — Revulsion — Utility of Revulsion — Experimental Researches on Revulsion 
— Reflex Paraplegias — Paraplegias from Cold — Hydro-therapy — Cold Douches and 
Warm Douches — Electricity — Ergot — Empirical Medication — Nitrate of Silver — Phos- 
phorus — How to Give Phosphorus — Treatment of the different Varieties of Myelitis — 
Treatment of the Hyperaemia — Influence of Decubitus — Treatment of Meningo-myelites 
— Treatment of the Consecutive Paraplegia — Electricity — Hydrotherapy — Thermal 
Treatment — Strychnine — Indications and Contra Indications — Treatment of Myelites 
by Compression — Anti-syphilitic Treatment — Treatment of Sclerosis of the Posterior 
Columns — Its Progressive March — Its Incurability — Bad Effects of Hydrotherapy — 
Thermal Treatment — Treatment of the Douleurs Fulgurantes — Injections of Morphia 
— Effect of Temperature — Nerve-stretching — Electricity — Treatment of the Atrophic 
Paralysis of Infancy — Electricity. 

Gentlemen: If it were incumbent on me to give the history of the diseases 
of the spinal marrow, this lecture would be far too long, for on no subject has 
so much study been spent the past few years as on theser spinal inflammations. 
Clinical medicine and pathological anatomy, based on physiological and ana- 
tomical studies which have had the spinal marrow for their subject, have enabled 
us to trace not only the tableau of diseases of the spinal cord and of its mem- 
branes, taken collectively, but also the various alterations which affect the 
different bundles composing the medullary axis. 1 Unhappily, therapeutics has 

1 If we make a section of the cord near its middle portion, we see that it is composed 
of two substances — one, the enveloping substance, the white medullary matter; the other, 
the substance enveloped, the gray matter. 

The disposition of the gray matter has been compared to a capital H ; the vertical lines 
are represented by the lateral parts of the gray substance, which, curving outwards, by their 
extremities take the form of a crescent; the horizontal line is a portion of gray substance 
which contains within itself the canal of the ependyma, and bears the name of gray commis- 
sure. The parts of the crescent situated in front of the commissure are the anterior horns; 
those situated behind^are the posterior horns. 

As in the nervous system generally, this gray substance is in greater part composed of 
cells, which form the nuclei of origin of the spinal nerves. 

The cells of the anterior cornua are much more voluminous than those of the posterior 
cornua. It is in these groups that the anterior or motor roots take their origin by three 
bundles of fibres. Add that they seem to possess atrophic besides a motor function; it is 
these cells, in fact, that are diseased in progressive muscular atrophy and in the wasting 
paralysis of infancy. 

The posterior horns are invested (coiffed) at their free extremity by a substance com- 
posed of a connective tissue framework, and of cells concerning the nature of which nothing 
is definitely known (gelatinous substance of Rolando). 

The cells of the posterior horns are more irregularly disseminated than those of the 
anterior horns; they are grouped together in only one place, situated quite near the anterior 
horns (column of Clark). The posterior or sensory roots take origin from different points of 
the posterior cornu, and some even cross over to the cells of the anterior horn. It is by 
this disposition that the muscular atrophy which accompanies posterior sclerosis is explained. 

166 



ON THE TREATMENT OF CHRONIC MYEL1TES. 167 

not followed the unceasing progress of clinical study, and we are still obliged, 
as far as treatment is concerned, to make use of the same medicinal means here- 
tofore employed, and which are most generally inefficacious, so that, in a great 
number of cases, the idea of incurability accompanies the diagnosis of affections 
of the spinal medulla. 

Nevertheless, as the medullary diseases are frequent ; as, moreover, they 
have a long and progressive course, and will often claim your care, I have 
thought best to set forth the kinds of treatment most in use, recognizing at the 
same time their inefficacy. This inefficacy is easily understood when you take 
into account, on the one hand, the position of the spinal cord, which, surrounded 
by its membranes, is with difficulty reached by direct treatment, and, on the 
other hand, the very structure of the cord, which, in such small volume com- 
prises nerve-centres and conductors that establish a direct communication 
between the brain and the mixed nerves. 

The least alteration in the histological integrity of the spinal axis must 
then profoundly modify the functions of the parts over which this portion of 
the cord presides; and notwithstanding that we see- tumors, even of consider- 
able size, develop without apparent symptoms in certain portions of the cerebral 
mass, the least disorder, scarcely appreciable to the sight, in the substance of 

If now you examine the spinal cord when deprived of its envelopes, you observe in the 
middle line, before as well as behind, a fissure which separates it into two parts — an anterior 
fissure, quite large; and a posterior, more narrow, but deeper. In separating the edges of 
these fissures you notice, at the bottom of the first, a bridge of white substance called the 
white commissure, and at the bottom of the second a bridge of gray substance called the gray 
commissure. 

Laterally we see, on the posterior aspect, at each side of the posterior median fissure, 
another fissure which corresponds to the insertion of the posterior roots — the posterior lateral 
fissure, whose extremity is prolonged into the bulb to correspond with the cineritious tubercle 
of Rolando and the roots of the pneumogastric andglosso-pharyngeal nerves. 

Anatomists have described an anterior lateral fissure corresponding to the anterior 
roots; this fissure is purely imaginary, and, while the posterior roots take their origin on a 
line perfectly vertical, the anterior roots intercept by their origin a band of substance three 
or four millimeters in width. 

These fissures divide the spinal cord into a certain number of columns, three for each 
half of the cord — admitting an anterior lateral fissure — (anterior, lateral and posterior 
columns); generally, however, only two are described, the antero-laterat and posterior. , 

Beside these principal fissures, note the posterior intermediate fissure, situated two milli- 
meters from the median posterior fissure; it divides the posterior columns into an internal 
portion, the column of Goll, zone of ascending degeneration, and into an external posterior 
root zone, or column of Burdach, seat of the lesions of progressive locomotor ataxia. 

Such are the divisions perceptible to the sight, of the white substance of the cord. 
Besides these, experimental physiology, and especially clinical medicine, have made other 
divisions. The anterolateral columns have been subdivided, into several zones. At the 
internal portion, bounded on the one side by the anterior median fissure and on the other by a 
line proceeding from the antero-internal group of cells of the anterior cornu to the periphery of 
the cord, we see the direct pyramidal column of Turck (seat of descending degeneration). 
Externally to this column is the anterior root zone, seat of the lesions of progressive muscular 
atrophy. 

In front of the lateral posterior fissure, just anterior to the apex of the posterior horn 
and near the periphery of the cord, is a small zone, seat of ascending degeneration, 



168 ON THE TREATMENT OF CHRONIC MYELITES. 

the spinal cord, will make itself manifest by symptoms of great gravity. This 
fact explains why it is only since the application of histology to medicine that 
we have been able accurately to diagnosticate the affections of the medulla, 
since in most cases the pathological alterations, invisible to the naked eye, can 
only be studied by means of high powers. 

Standing, as we do, on therapeutic ground, our study of the myelites may 
be considerably abridged; for, directing our attention to the processes which 
determine medullary diseases, therapeutics need not distinguish the different 
myelites which are called systematic myelites, such as sclerosis of the posterior 
columns, sclerosis of the lateral columns, sclerosis of the anterior cornua, which 
clinical medicine and pathological anatomy have described as special morbid 
entities. What we have really to oppose is the connective tissue induration 
which produces these pathological changes, and the therapeutic means to em- 
ploy are the same in sclerosis of the posterior columns, and in sclerosis of the 
lateral columns. 

When we take a general survey of the diseases of the spinal marrow, we 
find that they may be referred to three principal types. In the first group are 
placed the different degenerations which affect the medullary axis and its en- 
velopes (cancer, syphilis, etc.); in the second, we meet the same alterations 
which we have studied in the preceding chapter on apoplexy, i.e., the rapid and 
sudden disorganizations of the spinal cord (spinal hemorrhage, spinal ramolisse- 
ment), produced by rupture, or serious lesion of the spinal bloodvessels. These 
are veritable medullary apoplexies. All the alterations of the third group have 
for their origin a hyperaemic and inflammatory process. It is with this last 
group, which is the most frequent, that we are now especially concerned; and 
if, in the anatomo-pathological details on which I am about to enter, I seem to 
vary somewhat from my customary method, it is because these details have, 
from the standpoint of therapeutics, a preponderating importance. 

called the direct cerebellar column, and between that and the body of the posterior horn 
there is an ovoid mass of fibres called the crossed-pyramidal column (zone of descending 
degeneration). 

What is the upward destination of the columns, anterior and posterior and lateral ? 

The anterior columns, which decussate the whole length of the cord (anterior white 
commissure), do not cross in the medulla oblongata, but become posterior. 

The lateral columns decussate incompletely and become anterior to form the superficial 
parts of the anterior pyramidal bodies. The non- decussating portion continues its course to 
form the lateral columns of the bulb. 

The posterior columns decussate completely; taking the same direction as the lateral 
columns, these columns lose themselves superiorly in the deeper strata of the corpora 
pyramidalia. 

As for the columns of Goll, they do not decussate ; they only change their direction 
and separate at the beak of the calamus-scriptoriiis , taking an upward direction obliquely and 
externally along the internal border of the restiform bodies, to penetrate with them into the 
cerebellum and assist in the formation of the inferior cerebellar peduncles (a). 



(a) Charcot, Lecons sur les maladies du systeme nerveux.— Herschfeld, Anatomie du systeme nerveux.— 
Sappey, Anatomie descriptive. — Fort, Lecons sur d'anatomie du systeme nervoux.— Jaccond, Traite des para- 
pldgies, Nouveau Diction., art. Nerfs. — Diction, encyclop^dique, art. Moelle. 



ON THE TREATMENT OF CHRONIC MYELITES. 169 

Inflammation of the spinal medulla presents itself under two distinct 
forms: in one, the hyperemia affects all the constituent parts of the cord, and 
causes their speedy disorganization; in the other, the inflammatory process, 
whether primitive or secondary, attacks only the connective-tissue element, de- 
termining a hyperplasia of the neuroglia, which speedily chokes out and 
destroys the nervous elements. 

Here, then, we again meet with that great division of inflammations which 
we have already seen produce so much mischief in the kidneys and in the liver, 
and just as we have interstitial and parenchymatous nephritis and hepatitis, so 
also we have interstitial and parenchymatous inflammations of the spinal cord. 

As for parenchymatous myelitis, I have shown in my theses d' agregation on 
acute myelitis 1 the march of the inflammatory process, and I have dwelt especi- 
ally on the first period called the stage of tumefaction, and which results not 
only from the vascular hyperemia, of which the medulla is the seat, but also 
from the swelling of the neuroglia and the nervous elements. 

In interstitial myelitis, the neuroglia appears alone to be affected. By the 
organization of its cellular elements, under the influence of an indurating pro- 
cess, it chokes out the nerve-cells or tubes. Vulpian, in his remarkable lessons 
on the diseases of the spinal cord, has dwelt at great length on the pathogeny of 
this sclerous process, especially under the head of locomotor ataxia, and he 
adopts the view that the proliferation depends on primitive irritation of the 
nervous elements. But this is not the only opinion advanced: some, as 
Ordonez, maintain that the vascular alterations are the primitive cause of the 
sclerosis; others affirm that the hyperplasia of the neuroglia is primitive. I be- 
lieve that both hypotheses are correct, and that, from a therapeutic standpoint, 
we ought to make a great account of them. 

What can medicinal agents accomplish in cases of parenchymatous or in- 
terstitial myelitis? In parenchymatous myelitis we cannot do much, except in 
the period of tumefaction, and as we cannot influence either the neuroglia or 
the nerve-tubes, we can only hope to modify on the circulation of the cord. When, 
however, the exudation has taken place, and the medullary substance is 
destroyed, it will be impossible for us to repair the disorders which result 

1 In his work on acute myelites {these agreg., Paris, 1872) Dujardin-Beaumetz studies 
the pathological anatomy of this disease; he describes three states corresponding to divers 
degrees of the inflammation; these are swelling, ramollissement, resorption. 

1. The swelling results from augmentation of the circulation, from tumefaction of the 
connective-tissue framework, and from modifications effected in the nervous elements them- 
selves and which are chiefly characterized by dilatation of the axis cylinders and great in- 
crease of size of the multipolar cells. (Charcot.) 

2. The ramollissement is produced by the exudation which transudes from the vessels, 
and which causes disintegration of the constituent parts of the cord determining in certain 
cases veritable hemorrhagic foci. When the softened portions are examined by the micro- 
scope there is found debris of cells and nerve tubes, hyperaemic vessels whose lymphatic 
sheath is gorged with cells, little drops of myeline, granular bodies and fatty and pigmentary 
granulations. 

3. The resorption of these parts constitutes foci of cicatrization, or lacunae which are 
observed when acute myelitis does not cause disorders incompatible with life, and which are 
especially noted in localized myelites. 



170 ON THE TREATMENT OF CHRONIC MYEL1TES. 

from the softening. In the case of interstitial myelitis, we are impotent to 
arrest the hyperplasia of the neuroglia, and the disorders which are its conse- 
quence, and all that we can do is to diminish the nervous irritation which 
this hyperplasia determines, or the hypersemia of which the latter is the result. 

To sum up, then, our therapeutic endeavors must first be directed to com- 
bating the primary causes of the inflammation; 1 secondly, to opposing the hy- 
peremia of the cord. Apart from this twofold duty, we are powerless, and the 
utmost that we can do is to mitigate the consequences which result from the 
medullary changes, and which are so detrimental. I shall briefly review the 
various therapeutic agents which we can employ, then make special application 
of them to the different spinal affections. 

To fulfil the first of these indications is often easy, and in the case of 
myelitis by traumatism or by compression, it will be sufficient to remove the 
foreign body which irritates or injures the cord to cause disappearance of the 
resulting inflammatory symptoms. In the case of Pott's disease, with lesion 
of the vertebrae, special surgical appliances are necessary to remedy the spinal 
deformity which produces compression of the cord, and causes paralysis. In 

1 According to Vulpian the different causes of acute myelitis are as follows: i. Myelitis 
by propagation; this kind of myelitis begins in meningitis and affects at first the superficial 
strata of the cord and may propagate itself toward the centre and even reach the gray sub- 
stance; this invasion may take place with great rapidity; to the symptoms of meningitis are 
added those of myelitis and the lower limbs are paralyzed. 

2. Myelitis by tumors, intra or extra medullary j these are the acute or sub -acute 
myelites which accompany tubercles, gummata, cancer, sarcoma, etc., of the cord. 

3. Myelitis by traumatic violence; these result from wounds, commotions or contusions 
of the cord. It is this kind of myelitis which is produced artificially in animals. 

4. Myelitis by excess of fatigue; this kind of myelitis is produced by excess of functional 
activity of the medullary elements; it sometimes results from overwork. 

5. Myelitis from cold. Cold may determine myelitis. Frinberg succeeded in thus pro- 
ducing it in hares by spraying the shaved backs of these animals with ether; the resulting par- 
alysis was well marked. The autopsy revealed diffuse myelitis. Vulpian explains the mye- 
litis a frigore by the speaial irritation determined by cold' on the peripheral extremities of 
cutaneous nerves, an irritation which troubles the trophic functions of the parts of the cord 
from which spring the sensory and sympathetic fibres, destined to the meninges, thus causing 
perturbation of the nutrition of the anatomical elements of these membranes; phenomena of 
a similar kind take place in the medullary substance also. 

6. Myelitis by irritation of peripheral nerves. These are the myelites which are habitually 
described under the name of myelitis by reflex action; they result from the alteration effected 
in the cord by the irritation of certain nerves; this myelitis has been reproduced experiment- 
ally by Tiessler, Frinberg, Klemm, Hayem, by irritating with mechanical or chemical excit- 
ants the sciatic nerves. 

7. Myelitis of toxic origin. These myelites are chiefly met in lead poisoning and poison- 
ing by alcohol and phosphorus. 

8. Myelitis by general diseases. It is in this group that are found those myelites deter- 
mined by small-pox, typhoid fever, diphtheria, syphilis; those which are observed as a sequel 
of acute diseases and which have been described by Gubler as consecutive to dysentery and 
puerperal affections, (a.) 



(a) Vulpian, Maladies du systeme nerveux (Maladies de la Moelle, Paris, 1879, p. 160). 



ON THE TREATMENT OF CHRONIC MYELITES. lVl 

the case of syphilitic gummata and exostoses, the specific treatment will some- 
times remove the inflammation and its products. 

In other cases, we can do much to prevent inflammatory mischief by 
hygienic measures. Whether the medullary sclerosis be primitive and the 
result of repeated. congestions of the spinal cord; whether it be secondary, from 
irritation of the nervous elements (Vulpian), it is not the less true that every 
excessive exercise of function on the part of the cord and its integral divisions 
may be a predisposing cause of sclerosis. Therefore, forced marches, too 
prolonged muscular labors, may determine veritable myelites, which are 
described under the name of myelitis from strain (surmenage), and which are 
observed in animals as well as in men. The abuse of the genital functions, 
and, in particular, coitus while standing, enter into the same group, and have 
often been invoked as the determining cause of tabes. You readily see, then, 
how much may be done by hygienic measures of prevention when once these 
causes are known; and I pass to the second indication, which is to combat the 
medullary hyperemia. 

The circulation in the spinal cord is very active; a multitude of venous 
and arterial vessels from numerous sources form around its bony canal and 
membranes a rich vascular plexus, which it is difficult for us to reach by any 
direct means. As, however, the spinal vessels and the vaso-motors which 
innervate them can be affected reflexly (vide Vulpian, Appareil Vaso-Moteur, t. 
ii. p. 49), you readily understand that by an action limited to points more or 
less distant from the spinal axis we may modify the circulation in the cord, and 
it is on this action that revulsive medication is based; a kind of treatment which 
is first in importance in spinal affections. 

Although tradition from the dawn of medical history has affirmed the 
beneficial influence of energetic revulsion in diseases of the spinal cord, in our 
time certain physicians have denied this favorable action, and have maintained 
that revulsion increases the suffering of patients without ameliorating their 
condition. This, gentlemen, is a mistake, and facts of experimental physiology 
confirm most unequivocally the results which clinical medicine has accumulated 
during the ages. 

What, then, has experimental physiology taught us on this point ? From 
a great number of conclusive observations I select the following : You are 
all "familiar with the results which Vulpian obtained in electrizing a nervous 
branch communicating with the intra-thoracic chain of the great sympathetic; 
there was most marked contraction of the blood-vessels of the region of 
the spinal cord, from which was derived the intercostal nerve with which 
the nervous filament electrized was in relation. In his numerous and 
remarkable researches on the circulation of the spinal cord, Brown-Sequard ? 
after tying or irritating the nerves of the kidneys or suprarenal capsules, 
observed a contraction of the blood-vessels of the cord on the side which 
was irritated. 1 Frinberg obtained a paralysis a frigore in a hare, on 

1 Brown-Sequard, Lessons on the Diagnosis and Treatment of the Principal Forms 
of Paralysis of the Inferior Extremities, Paris, 1864. — Frinberg, Ueber, Reflexlahunungen 
(Berlin, Klin. Wochensch, 1871, Nos. 41, 42, 44, 45.) 



172 ON THE TREATMENT OF CHRONIC MYELITES. 

spraying with ether the skin of the back which he had previously shaved. 
As you are well aware, on this very reflex action the theory of so-called 
reflex paralysis has been based, also of myelitis and meningo-myelitis a f rigor e. 
Without entering into the long discussions which have arisen on this subject, it 
has been determined both by experiments on animals and by clinical experience 
that external excitations made on the skin do modify the circulation in the 
spinal cord and its envelopes. Let us now examine the agencies utilized in 
revulsive medication in these affections. Everything has been employed, from 
frictions with irritant ointments to the cautery and moxa. The latter revulsives, 
which were till recently the most in use, are to-day being abandoned, being 
advantageously replaced by punctiform galvano-cauterizations. The use of 
caustic potash or Vienna paste is likely to be attended with certain incon- 
veniences, and in particular that of producing suppurating sores over the 
vertebral column ; these last some time, and are not without danger to patients 
who are obliged to maintain the dorsal decubitus, and whose skin performs its 
functions badly by reason of trophic disturbances determined by the medullary 
affection. 

The electrical points, on the contrary, rendered so easy of management by 
the invention of the cautery of Paquelin, present all the advantages of energetic 
cauterization without the least inconvenience. Moreover, these cauterizations, 
which do not cause troublesome sores, may be renewed every eight days. You 
practice them along the spinal column, right and left of the middle line, puncti- 
form cauterizations in parallel series, and in number varying according to the 
exigency of the case. These cauterizations are preferable to vesication by the 
cantharidal blister, for the vesicatory, besides removing the epidermis, deter- 
mines troubles in micturition, a function generally more or less disturbed in 
diseases of the spinal cord. In certain cases the seton may be employed; this 
is one of the most powerful revulsives that I know of, but it is of especial utility 
in affections of the brain and upper portions of the spinal cord. 

To the revulsive treatment we may join the application of cold, which also, 
as we have seen by the experiments of Frinberg, may modify the circulation in 
the spinal cord. But in order to obtain durable effects it is necessary to 
prolong the applications of ice, and this is always inconvenient. Pulverizations 
of ether by the spray apparatus, if they could be continued sufficiently long, 
would be indicated in these cases where the physiological effect of cold is 
desired. 

Hydrotherapy applied to the treatment of medullary affections, is a two- 
edged sword, which must be managed with great prudence. In fact, it does not 
cause anaemia of the spinal cord. In the majority of cases it congests it, and 
this it is which explains the successes and the aggravations which have been 
obtained. Successes, when one has to do with those paralyses, sine materia, 
which appear in the course of neuroses, or those which have a dyscrasic origin, 
and which accompany diphtheria and other acute diseases, also those parapleg- 
ias observed in anaemia and chlorosis; aggravations, when the indication is to 
combat inflammatory and sclerous processes, for in these cases hydrotherapy, by 



ON THE TREATMENT OF CHRONIC MYELITES. 173 

inducing congestion of the cord, favors rather than opposes the hyperplasia of 
the medullary neuroglia. 

To avoid these disadvantages, warm douches have been advised, or tem- 
pered douches, as Beni Barde has recommended, but it is always important 
when you employ either cold douches or tempered douches, to examine with 
care the cutaneous sensibility, often strangely perverted in patients affected 
with spinal diseases. 1 

We have seen that electricity applied over the bony canal of the spinal 
cord modifies the medullary circulation; from this has resulted the employment 
of electricity in the treatment of congestions and inflammations of the cord. 
Two methods are in current practice. In the one you make use of faradic cur- 
rents (here the portable battery does good service), and with the electric brush 
you make energetic revulsion along the vertebral column. I have seen happy 
results from this faradic treatment in tabes dorsalis. Jn other cases you apply 
galvanic currents up and down the spine; there has been much dispute about 
the direction of these currents, some being of opinion that ascending, others 
that descending, currents are preferable. I believe that the direction is a 
matter of little consequence, and that one may use indifferently either ascend- 
ing or descending currents. 2 To cauterizations, to applications of ice, to 

1 Beni Barde observes with justice that the sense of temperature in tabetic patients is 
sometimes so perverted that they cannot distinguish cold from hot water; the feelings of 
such patients would not be a safe criterion as to the heat to which the water might be raised. 
(Beni Barde, Traite theorique et pratique d'hydrotherapie, Paris, 1874, P- 808.) 

2 Faradic currents have been employed in ataxia by Duchenne, but this treatment has 
not given very satisfactory results; at the same time, in the first periods of the disease, 
faradisation of the skin may help the lightning pains. 

Constant currents have been much more employed. Remak has even affirmed that 
they may have a direct action on the sclerosing processes, but this is a mistake, for the cur- 
rents have never caused a complete cure, but simply occasional amelioration — as Erb's 
statistics show, who out of 66 cases of locomotor ataxia treated by galvanism, has noted 41 
ameliorations and 21 failures. 

As for the direction of the currents, opinions vary; Rosenthal employs currents directed 
across the cord and ascending currents. 

Onimus insists on the necessity of employing ascending currents, and he often 
places the positive pole in the lumbar region, and the negative pole in the cervical 
region. 

Benedict proceeds in the following manner: He electrizes the cord every day for from 
three to six minutes. If the troubles of motility predominate, he electrizes at the same time 
the cord and the nerves and muscles. When there are no phenomena of excitation and of 
spasm, he electrizes the cord, without concerning himself with the direction of the currents, 
and by putting the two reophores over the spinal cord. 

To combat the ocular troubles, electricity has also been used. Benedict recommends 
centripetal electrization of the trifacial. Erb, on the other hand, advises the employ of a 
centrifugal current. Leon Le Fort, Reynolds, Boucheron, affirm that the direction of the 
current is a matter of no importance, and they place one of the poles on the nucha, and the 
other on the forehead, (a) 



(a) Onimus et Legros, Traite d'electricite medicale, Paris, 1872, p. 430— Hammond, Traite des maladies 
du systeme nerveux, trad, de Labadie Lagrave, p. 712. 



174 ON THE TREATMENT OF CHRONIC MYELITES. 

electricity, we must add certain internal medicaments, of which the purpose is 
to diminish the congestion, or the connective-tissue hyperplasia which results 
from it. As for certain of these medicines, their application is the result of the 
knowledge of their physiological properties; as for others, empiricism has led 
to their adoption and usage. We will pass rapidly in review the greater part 
of these remedies. 

The curious property which ergot of rye possesses of causing contraction 
of the capillary net-work has been utilized in affections of the spine; and Brown- 
Sequard is one of the most strenuous partisans of this therapeutic employment 
of ergot. The results which I have obtained from this medicament in spinal 
sclerosis have not answered my expectations, and I believe that the use of ergot 
in these diseases is based on theoretical considerations rather than on sound 
clinical experience. 

Ergot is given in substance or in the form of ergotine or ergotinine. The 
hypodermic method of administration may be adopted, injections being made 
over the spinal region with ergotine or ergotinine. The dose of the latter 
ought not to exceed two milligrammes (one-thirtieth of a grain), and one milli- 
gramme is enough for an ordinary dose. 

Strychnia has been recommended in the treatment of the diseases of the 
spinal cord, but, as Vulpian remarks, the therapeutic action of this alkaloid hav- 
ing no influence on the morbid process, the cause of the paralysis, and strychnia, 
moreover, being incapable of removing the disorders which result from the 
inflammation, no curative effects can be expected from this medicament in acute 
or chronic spinal affections. I go further, and add, that often the action of this 
drug is injurious by reason of its irritating influence on the medullary axis. It 
is best, then, to be very chary in the use of strychnia; and even to discard it 
altogether in congestions of the cord, and never to use it except in the case of 
paralysis called essential, or sine materia} 

It has been claimed that iodide of potassium has also an action on the 
circulation of the spinal cord, and that it is capable of ansemiating it. I believe 
that the good effects which have been obtained from this medicament are not 
the result of the influence of the iodide on the circulation, but of its specific 
and resolvent action on products of a syphilitic nature. A great number of 
tabetic patients are syphilitic, and are therefore likely to be benefited by the 
iodide. 

Bromide of potassium has an important role in the treatment of diseases of 
the spinal cord, not because it has any direct effect on the phlegmasic process 
acute or chronic, but because it tends to diminish the excito-motor power of 

1 Fouquier has remarked that when strychnine is given to paraplegic patients, convul- 
sive manifestations in the paralyzed members often ensue. When the spinal cord is no 
longer in communication with the brain, its excito-motor power is augmented, and strychnia 
greatly enhances this reflex excitability. When, in a frog, you cut the spinal cord trans- 
versely, and inject strychnia, it is in the inferior members that the first effects of the poison 
are seen; but as Vulpian well observes, in order that this action may be produced in para- 
plegic persons, it is necessary that reflex excitability be preserved in the paralyzed limbs. 
(Vulpian, Substances toxiques et medicamenteuses, Paris, 1882, p. 580.) 



ON THE TREATMENT OF CHRONIC MYELITES. 175 

the cerebro-spinal axis; the bromide, then, is indicated whenever signs of irrita- 
tion or excitation of the spinal medulla supervene. 1 

Empiricism has made great account of two medicinal agents in the treat- 
ment of medullary sclerosis, nitrate of silver and phosphorus. 

Nitrate of silver was recommended for the first time in 1861, by Wunder- 
lich, 2 but it is especially to Charcot and Vulpian that the employment and 
popularity of this remedy in locomotor ataxia are to be ascribed. 

Nitrate of silver is given in pills of one centigramme; at first one, then two, 
then three, then four of these pills a day, the last dose never to be exceeded. 
This medication, which is only of utility after the inflammatory symptoms have 
subsided, may give you in some cases amelioration and even cure, if the obser- 
vations reported by Wunderlich, Rosenthal, Hammond, etc., may be relied on; 
but it is well to bear in mind that these are exceptional cases, and for my part 
I have to confess that I have never obtained, even from the prolonged use of 
nitrate of silver, any results worth mentioning. 

Do not forget that the medullary sclerosis for which nitrate of silver is 
employed, does not progress in a uniform manner, and that it presents periods 
of ascension, and periods of arrest; it is easy then to understand that according 
to the precise time in the evolution of the disease in which the medicament is 
administered, amelioration or aggravation of the symptoms may be observed. 

How does the remedy act? We are wholly ignorant. Does imbibition of 
the silver salt by the neuroglia hinder the proliferation of the latter? Does the 
medicine act on the nervous elements themselves? These are questions which 
we cannot answer. 



1 Siredy noted the good effects of bromide of potassium in a case of locomotor ataxia, 
effects already witnessed by Vulpian. His dose was two grammes, gradually increased to 
six grammes each day. 

2 Wunderlich was the first to administer nitrate of silver in this disease. Out of five 
cases treated by him, in 1861, there was one recovery. The year following Charcot and 
Vulpian published a monograph on the subject. They administered the nitrate in pills of one 
centigramme each; at first two, then three, and seldom more than four pills a day. Of five 
cases treated by them with this remedy, there was in all great amelioration; the lightning 
pains disappeared, and the muscular movements gained in force and precision. 

After the publication of Charcot, Moreau, then Beau reported cases of cure by nitrate 
of silver. In Germany, Kiichenmeister reported observations in which the medicament pro- 
duced no effect. In 1863, Wunderlich published in Archiv der Heilkunde, another memoir in 
which were recorded cases of amelioration and cure under medication by nitrate of silver. 
Rosenthal. Hammond, etc , have also noted recoveries in ataxia from nitrate of silver. 

Teissier, of Lyons, after showing that the locomotor ataxia described by Duchenne of 
Boulogne, and the tabes dorsalis of Romberg, are one and the same disease, is emphatic in 
his praises of nitrate of silver in this malady. The results are variable, sometimes there is 
improvement in the power of muscular coordination, sometimes only the painful manifesta- 
tions are relieved. 

(Wunderlich, Archiv der Heilkunde, 1861-1863; Charcot and Vulpian, Bull, de Ther., t. 
62, p. 481; Moreau de Tours, Union Med., Oct. 1862; Beau, Bull, de Ther., J863, t. 64, p. 
315; Trousseau, Bull de Ther., t. 64, p. 82; Hammond, On Diseases of the Nervous System, 
p. 709; Tessier, De Valaxie loc. et de son traitement, 1864. 



176 ON THE TREATMENT OF CHRONIC MYELITES. 

I was the first (in 1868) to propose the use of phosphorus in locomotor 
ataxia. 

Delpech had several years before (in 1863) applied phosphorus to the 
treatment of certain paralyses from chronic poisoning, and in particular to that 
produced by sulphide of carbon. I have continued this phosphorus medication, 
and, although I have never obtained a cure by this remedy, I have in many in- 
stances noted amelioration, characterized by a sensation of increase of force, 
and diminution of incoordination. But the same reservations which I made 
a pi'opos of nitrate of silver, ought to be made here, and one may well ask if in 
many cases the amelioration obtained is not rather the consequence of the 
natural march of the disease than of the action of the medicine. My pupil, Dr. 
Eugene Lemaire, has published in his remarkable thesis on the employment of 
phosphorus the greater part of those observations. 1 

This phosphorus medication needs to be closely watched, and I am going 
to enter into certain details which appear to me to be necessary. When I com- 
menced my experimentation with phosphorus, I immediately stumbled against a 
difficulty, the unreliability and the danger of the preparations in use; and I 
proposed to substitute for the phosphorated oil of the codex, 2 solutions of phos- 
phorus in chloroform, of definite strength, and I also had capsules made con- 
taining one milligramme (^ grain) of phosphorus. But attention was awakened 
on this point, and thereupon successively appeared the monographs of Mehu 
and Vigier. 

Mehu showed that while the oleum phosphoratum of the codex, as ordinarily 
prepared, is of uncertain strength, a sufficiently good solution might be had by 
heating the oil very hot, and henceforth unalterable capsules of phosphorated 
oil might be obtained, each containing one milligramme of phosphorus, Vigier, 
by his studies on the metallic phosphides, showed the advantage which might 
be derived from these preparations, and he introduced phosphide of zinc into 
therapeutics. 3 These capsules of phosphorated oil, and Vigier's pills of phos- 
phide of zinc, are to-day the preparations of phosphorus most in use. 

When you prescribe phosphide of zinc, do not forget that four milli- 
grammes represent one milligramme of phosphorus. Whether you make use 
of granules of phosphide of zinc containing four milligrammes, or capsules of 
phosphorated oil containing one milligramme, you ought to observe the follow- 
ing rules: Commence with one pill, or one capsule, and increase gradually till 
ten are taken in the twenty-four hours; continue this dose three or four days, 

1 Dujardin-Beaumetz, sur l'Emploi du phosphore en medecine et en particulier dans 
l'ataxie locomotrice progressive. Bull. Gen. de Ther., 1868, t. lxxiv. pp. 16, 157, 203, 302. 

N. Gueneau de Mussy, On the Treatment of Mercurial Trembling by Phosphorus. 
Gaz. des Hop., 1868, Nos. 48 and 50. 

Lemaire (Eug.), On the Therapeutic Employment of Phosphorus in Certain Affections 
of the Nervous System. These de Paris, 1875, No. 143. 

2 The phosphorated oil of the codex contains two grammes ( 3 ss) of phosphorus to one 
hundred grammes ( § iij, 3 ijss) of oil of sweet almonds, and is an uncertain preparation. 

3 Vigier, On the Therapeutic Employment of Zinc Phosphide (Bull. Gen. de Ther., t. 
lxxiv. p. 268). 



ON THE TREATMENT OF CHRONIC MYELITES. 177 

then suspend the medicine for five days, to renew the treatment by commencing 
with one capsule. These interruptions in the phosphorus medication are neces- 
sary in order to avoid accumulation of action, and to permit the medicine 
to be eliminated. In following these rules the phosphorus treatment can be 
continued with safety for months or for years. I add that in order to render 
the medicament more tolerable to the stomach, you would do well to order the 
phosphorus to be taken at meal time, you will then avoid in great part the 
eructations of lucifer -match taste which follow the administration of this remedy. 
There is another caution to be observed in prescribing phosphorus in tabes. 
It will not do to give it when there are any symptoms indicating any 
considerable degree of congestion or irritability of the nervous system, nor in 
the case of gastro-intestinal troubles; moreover, to get any good from the 
phosphorus treatment it must be continued a long time. 

On what is this action of phosphorus in locomotor ataxia based ? Here, as 
in the case of nitrate of silver, we are obliged to make hypotheses. My own 
theory is the following: Ranvier, in his experiment with phosphorus, has shown 
that when this metalloid is inserted under the skin of animals, you do not pro- 
voke inflammatory disorders, but you determine arrest of the formative and 
nutritive operations of the histological elements. It is possible that in the 
spinal cord phosphorus thus opposes the proliferation of the neurolgia; but, I 
repeat, this is only a hypothesis, and I give it for what it is worth. 

Now that we have taken a general survey of the different modes of treating 
medullary affections, let us study the indications of treatment in the different 
forms of myelitis. I cannot here speak of all the varieties of spinal inflamma- 
tion — their number is considerable. You will find in the work of Grasset a table 
(see next page) which gives a good summary of all the kinds, and which will enable 
you to judge of their number. I shall only call your attention to those cases which 
you will oftenest be called to treat, the congestions of the spinal cord, the 
meningo-myelites, the myelites by compression, sclerosis of the posterior col- 
umns, disseminated sclerosis, and, in fine, that form known as atrophic paralysis 
of infancy, or sclerosis of the anterior cornua. 

The congestions of the spinal cord are frequent, and their causes are 
multiple; 1 they do not generally entail anything more than a relative incapacity 

1 The causes of congestion of the spinal cord are numerous; the most frequent are: 

Exposure to a very cold temperature, the incipient stage of fevers, especially paludal 
fevers, small-pox, and typhoid fever. Next in order of frequency come alcoholic excesses, 
venereal excesses and a too prolonged standing posture, extraordinary muscular fatigue, 
violent exertion, sometimes convulsive attacks; even the suppression of an habitual flux, 
menstrual or haemorrhoidal, etc. 

Traumatisms, blows, or falls injuring the vertebral column, may produce spinal con- 
gestion; also sudden changes in the exterior atmospheric pressure on the body. Rabington, 
Cuthbert and Clark have published instances of congestion so produced in laborers who, 
working in diving-bells, had been in the habit of abruptly entering or leaving these compart- 
ments of compressed air. 

Passive congestion has for its cause venous obstruction, as is observed in cirrhosis of 
the liver, pregnancy, abdominal tumors, and diseases of the heart or lungs. 

The symptoms of spinal congestion consist especially in lumbar or dorsal pains, rarely 



178 



ON THE TREATMENT OF CHRONIC M-YELITES. 



CLASSIFICATION OF THE MYELITES. 
(From Grasset's "Maladies du Systeme Nerveux") 
' (i) Of the ex [ 



Myelites sys- 
tematized, 
or paren- 
chymatous 
(beginning 
and pro- 
pagating 
themselves 
by the ner- 
v o u s ele- 
ments, lo- 
calizing 
themselves 
in a par- 
ticular sys- 
tem). 



Of the white 
columns 
(fasciculat- 
ed sclero- 
sis). 



Myelites dif- 
fuse or in- 
terstitial, 
beginni n g 
and pro- 
pagating 
themselves 
by the con- 
nective tis- 
sue; invad- 
ing indis- 
c riminate- 
ly all the 
regions of 
the cord. 



Of the poste- 
r i o r col- 
umns. 



(a) Primitive. Progress- 
ive locomoter ataxia. 

(b) Secondary. 



ternal part of | 
t he posterior ■{ 
columns (poste- j 
rior root zones). [ 

Of the internal [" ^/^ ixXx 

terior* columns \ ^ Secondary t 

n of the cord. 



part of the pos- 
ms 
of 



Of the lateral 
columns 
and pyra- 
m i d s of 
Turck. 



(colu m n s 
Goll). 



(i) Primitive. Lat- 
eral, symmetri- 
cal sclerosis. 



Of the gray 
substance. | 



Of the ante- 
rior horn. 



Of the bulbar 
nuclei. 



of columns of Goll. 
, to 
lesion 

Secondary ascending 
t sclerosis 
f (a) Without muscular 
atrophy. Spasmodic 
\ tabes dorsalis. 
j (b) With muscular atro- 
phy: lateral amyo- 
[_ trophic sclerosis. 
(2) Secondary to sclerosis of the cerebrum 
or of the cord; secondary descending 
sclerosis. 

(1) Chronic. Progress- 
ive muscular atrophy. 
f In the child 
— atro- 
phic in- 
fantile 
paralysis. 
In the 
adult- 
acute spi- 
nal par- 
[_ (^ alysis. 

Secondary to another myelitis. {Secondary 

spinal amyotrophy.) 
Primitive. Labio- f Simple, 
glosso laryn- < With muscular atro- 
geal paralysis. (_ phy. 
Secondary to different myelites. Bulbar 
symptoms in amyotrophic lateral scle- 
rosis, the diffuse myelites, etc. 



Primitive. 



(2) Acute 



Not 



Acute. .■■< 



Acute 
and 
sub- 
acute 
types 

f Sub-acute 
type 



Apoplectiform type (fou- f 
droyant). 

f Mortal, with re- 
covery; with 
] relapses; 
) with passage 
I to a chronic 
sta^e. 



Chronic. 



invad- 
ing; cir- 
cu m scrib- 
ed, more 
or less ex- 
tensive. 

Invading 

(acute as- 

c e n d i n g 

paralysis). [ Acute type. 
Not invading, ) Complete 

circumscribed. ) Hemilateral 

Invading. 
Sub-acute 

spinal par- 

alysis of 

Duchenne, 

generalized 

diffuse mv- 



Varieties: Dorso 
lumbar or cervi- 
cal. 

Complete or hemi- 
lateral. 

Central or periph- 
eral. 



Type with 
ascendi n g 
march. 



I 



e 1 i ti s of 
Hallopeau. J 

Special forms. 



Type with 
descend 
ing march. 



) Dorso- lumbar. 
\ Cervical. 

f Complete lesions. Lesions pre- 
dominating in the gray sub- 
stance (anterior spinal par- 
alysis of Duchenne, peri- 
epididymary myelitis of Hal- 
lopeau. 
Lesions predominating in the 
white substance. Annular 
cortical myelitis of Trousseau 
and Vulpian. 

i ^Sclerose en plaques, (multiple 

■] sclerosis). 

( General progressive paralysis. 



ON THE TREATMENT OF CHRONIC MYELITES. l7& 

or paresis of the lower extremities, a paralysis in its nature curable. As in 
every hypersemia, the first indication is to suppress the cause of which it is a 
manifestation; and whether the medullary hypergemia depends on rheumatism, 
on uterine or hemorrhoidal congestion, on too prolonged dorsal decubitus, on 
exaggerated fatigue, or on sexual excesses, your therapeutics should be varied to 
meet the causal indications. Rheumatism is one of the most frequent causes of 
congestion of the spinal cord, and, for my part, I remember to have observed, with 
Lasegue, during my earlier student days, a very curious case of sudden para- 
plegia in a kitchen maid; it was a result of acute articular rheumatism, and 
disappeared when the joints became affected. In these cases you understand 
the utility of dry or wet cups along the spine, of steam baths, and salicylate of 
sodium. At other times you will have to deal with simple paralysis a frigore, 
reflex paralysis from the impression of cold on the cutaneous surface. Here the 
treatment is different; besides the ordinary revulsives, such as blisters to the spinal 
region, you may employ sudorifics, and particularly pilocarpine, which, by the 
cutaneous congestion which they produce, have a favorable effect on the paraly- 
sis. Prolonged fatigue, by reason of the physiological congestion which it occa- 
sions in the spinal cord, is a factor in the etiology of this affection; here you 
must enjoin absolute rest, as well as revulsion. This word rest leads me to 
speak of the effect of dorsal position in the affections of the cord. Lying a 
long time on the back induces, as you well know, passive congestion of the 
spinal medulla, and it is probably to this congestion that we are to attribute the 
nocturnal erections which take place during sleep. You understand, then, that 
this fact has a certain influence in affections of the cord, and you will see 
patients predisposed to spinal congestion who, by reason of the dorsal decubi- 

acute, accompanied by a sensation of numbness and formication in the legs. The patients 
complain also at times of an intense feeling of heat in the back. 

When the inflammation is seated in the dorso-lumbar region, the inferior members 
present troubles of sensibility and motility; there are sensations of pricking, crawling, or 
tingling, in the limbs, numbness in the toes; the skin also presents,,anaesthetic points existing 
concurrently with hyperesthesia. 

Motility is more or less affected. There is always paraplegia, generally, however, 
incomplete; the patient walks with difficulty, dragging his legs along; at a more advanced 
stage he can no longer walk, he keeps his bed, but even then he can move his legs when he 
is lying down or sitting up. 

The muscles of the bladder and rectum are often paralyzed; there is retention of urine 
or incontinence, and sometimes retention of fecal matters. 

In active congestion of the cord, the invasion is sudden and the course is rapid; the 
pains are more severe, and the paraplegia complete. 

In passive congestion the symptoms develop more slowly, appear more tardily, and 
the pains sometimes precede by several days the appearance of the paraplegia which remains 
incomplete. 

In the active form the reflex movements are often exaggerated; they preserve their 
integrity in the passive form. 

The duration of the disease is variable. Passive congestion lasts as long as the causes 
which originate it. 

Congestion caused by traumatism, by an eruptive or paludal fever, disappears in the 
course of a few days. When the inflammatory state persists with fever for several days there 
is reason to fear the development of a more serious affection. 



180 ON THE TREATMENT OF CHRONIC MYELITES. 

tus of the night can scarcely support themselves on their feet in the morning. 
This paresis disappears after standing a short time, with disappearance of the 
congestion which caused it. 

This fact has a certain importance, and Brown-Sequard has derived from it 
therapeutic hints. In anaemia of the spinal cord, he directs the patient to lie on 
his back, while in spinal hyperemia he is to lie prone on his abdomen 

Thus far I have said nothing of bloodletting, which has been much em- 
ployed in affections of the spine. Very much vaunted formerly by Ollivier, who 
advised in these cases, besides general bleeding, leeches to be applied in great 
number to the dorsal region, and wet cups, this antiphlogistic treatment is 
to-day well-nigh abandoned. 1 At the same time wet and dry cupping may 
render considerable service in active congestions of the spinal cord, and it is a 
therapeutic measure not to be neglected. 

Meningo-myelitis, whatever may be the cause, is one of the medullary 
affections the most frequently observed. It is characterized by two marked 
symptoms ; first, by pains, often severe, coming in paroxysms, and bearing con- 
siderable resemblance to the douleurs fulgur antes of ataxia and to sciatic neu- 
ralgia ; secondly, by impotence, more or less complete, of the inferior extremi- 
ties, with conservation of sensibility, the external portions of the medullary 
columns being alone affected. Here energetic revulsion is indicated, preferably 
by cauterizations along the spine. 2 You must also assuage the pain, for this is 
one of the symptoms of which the patient most complains. All the various 
remedial measures which I spoke of under the head of the neuralgias will have 

1 It is especially in the case of spinal meningitis and concussions of the spinal cord 
that Ollivier has recommended copious blood lettings ; these, to be general or local. He 
advises that when general blood letting is preferred this should be done thoroughly, and he 
insists on its repetition where the patient is young and vigorous ; where local bleeding is 
chosen he advises the application of wet cups the whole length of the spinal column, and 
each side of the spinous processes. 

With regard to cupping, Gosse of Geneva proposes that deep incisions should be made 
in the muscles along the vertebral grooves in order to open the veins which communicate 
directly with the spinal canal. 

Ollivier condemns this practice, (a) 

2 Debove has recently proposed in these obstinate cases a mode of treatment, especially 
applicable to sciatica, which consists in spraying the seat of pain with chloride of methyl. 
In sciatica the gas is projected over the tract of the nerve from a siphon bottle, furnished 
with suitable stop-cock and beak. Intense refrigeration is produced, followed by smarting 
and even vesication; the latter may be very troublesome if the spraying be too prolonged. 
Rightly managed, this mode of treatment is said to be of singular efficacy, and superior to 
any other. Debove claims astonishing cures where everything had failed. Desnos, Rendu, 
Lallier, Legroux, Sevestre, Robin, Letulle and Dujardin-Beaumetz have all tried this process 
with varying success. It seems to do good rather by revulsion than by refrigeration; the 
innervation of multitudes of sensory nerve terminations is modified by the methyl-chloride 
spray, and some marked sedation in the central nuclei of these nerves in the cord seems to 
follow; at least it is substantially in this way that Debove accounts for the success of this new 
treatment. — Trans. 



(a) Ollivier Traite des maladies de lamoelle epiniere, Paris, 1837, t, n, p. 299. 
Gosse, Des maladies rheumatoides, Geneva, 1826, p. 231. 



ON THE TREATMENT OF CHRONIC MYELITES. 181 

their place. Double sciaticas ought always to make you suspect meningo-mye- 
litis. But the most effectual means for allaying the pain is the subcutaneous 
injection of morphia, and, in fact, this alone will in many cases bring relief. 
You must also watch the functions of the bladder and intestines, which are 
often profoundly disturbed in these cases of paraplegia due to spinal disease. 

As for the condition of the bowels, we have either obstinate constipation or 
fecal incontinence. The constipation will yield to drastic purgatives ; these 
medicaments not only restore regular stools, but they act as revulsives and may 
thus modify the circulation in the cord and its membranes. In certain cases 
the most violent purgatives cannot overcome the constipation ; this is because 
the rectum is paralyzed and allows itself to be distended beyond measure by 
fecal accumulations. Here you will have to break up the fecal mass with the 
finger, or scoop it oat with a spoon in order to clear the rectum. 

As for fecal incontinence, the most scrupulous pains must be taken for 
cleanliness ; nothing is more important in myelitis, for trophic troubles are of 
common occurrence, and often, in spite of all your care, extensive bed-sores 
will form over the sacrum, and even around the anus, as a consequence of dor- 
sal recumbency. In these cases the fracture-bed will render great service ; it 
enables you readily to dress the bed-sore, and to vary the position of the 
patient. 

The disorders which meningo-myelitis inflicts on the urinary organs 
are still more serious. At first the patient often experiences some ten- 
esmus due to spasm of the bladder, tenesmus which soon gives 
place to retention or to incontinence. For the retention, you will be 
obliged to use the catheter, notwithstanding the liability to cystitis with purulent 
urine which it occasions. For the latter evil, and to prevent putrid absorption, 
it will be necessary to wash out the bladder with solutions of carbolic, boracic 
acids, resorcine, etc., at the same time giving internally benzoic acid, oil of 
sandalwood, turpentine, copaiba, boldo or buchu, which are antagonists of fer- 
mentation. • 

If retention of urine has inconveniences, incontinence has quite as grave; 
the incessant flow of urine irritates the genitals, soils the bedclothes and the 
clothing, and augments causes already existing of local gangrene and erysipe- 
latous inflammation of the skin. In the case of male patients, urinals have been 
perfected by the use of which they can escape these accidents, but it is not so 
with the paraplegic female, who must suffer all the ill consequences of the in- 
continence. 

When the inflammatory symptoms have subsided, then much can be done 
to restore the power of movement to the lower .extremities. Here hydrotherapy, 
massage, frictions, electricity, may render real service; but these measures 
should never be employed in the acute stage of the affection, for they would 
cause aggravation of the disease. 

Myelitis by compression demands the same local treatment as meningo- 
myelitis; it demands also a special treatment directed to the removal of the 
cause. If the latter be cancer of the cord or its' membranes, we can do nothing 
but alleviate pain by hypodermic injections of morphia. If it be Pott's disease, 



182 ON THE TREATMENT OF CHRONIC MYELITES. 

we can by an appropriate plaster jacket, as Sayre, of New York, recommends, 
do much toward straightening out the vertebral column, and removing the de- 
formity which is the cause of the compression. If the cause be syphilis, noth- 
ing can be more serviceable than the injections of peptonate or albuminate of 
mercury, which not seldom cause the myelitis and paraplegia rapidly to disap- 
pear. 

I come now to the treatment of the medullary sclerosis, and especially of 
the typical form oftenest met with in practice, progressive locomotor ataxia. 1 
This word progressive, by which Duchenne characterized the pathological entity 

1 Locomotor ataxia, described under the names of tabes dorsalis, spinal paralysis, 
atrophy or gray degeneration of the posterior columns of the cord, was scarcely known in 
France, before the researches of Duchenne de Boulogne, and our knowledge of the path- 
ological anatomy of the disease, dates especially from the memoir of Burdon and Luys. 

It is a chronic disease with slow and progressive march; seeming at times to be arrested 
in its progress it presents periods, more or less long, of quiescence; it takes four, five, six 
years and even more for its evolution. It is primitive or secondary; it commences ordi- 
narily between the ages of twenty and thirty years and seems to be more common in men 
than in women. It is often hereditary, the family history revealing ataxia or other diseases 
of the nervous system. 

Articular rheumatism, venereal excesses, nervous affections, traumatisms of the cord, 
may cause the development of the disease. 

The influence of syphilis, denied formerly, seems to-day indisputable, and according to 
Prof. Vulpian, out of twenty patients afflicted with locomotor ataxia, at least fifteen of them 
were old syphilitic cases. 

The evolution of the disease presents three periods: a first, or painful period; a second, 
or period of ataxia; a third, a period of paralysis. 

The first, or period of lightning pains and ocular troubles, may manifest itself sud- 
denly, but this is somewhat rare. In this event there are violent paroxysms of pain in the 
limbs, the head and the trunk; these attacks subside to return again at variable intervals. 

Oftener the invasion has not this suddenness and the pains do not present so much 
violence; the patient complains of transient, rapid pains. These pains, often quite severe, 
shoot downward through the lower limbs f like lightning shocks (douleurs fulgurantes of 
Romberg). At other times they resemble bites, pricks, pinchings; they may be 
accompanied by sudden starts. Of variable intensity, they are ordinarily transient, but 
may also be persistent and localize themselves indifferent points. When situated in the 
trunk the pains are constrictive (douleurs en ceinture) and their violence sometimes impedes 
respiration. In the face they affect the fulgurant type and the persistent or continuous type; 
the patient complains of constant pains, with exacerbation, and exaggerated sensibility of 
the skin about the orbits, at the root of the nose, or around the infra-orbital foramen; some- 
times even the patient says that it seems as if his eyes were being plucked out. On the part 
of the organs of vision you note troubles consisting of paralysis or paresis of the third or 
fourth pairs of cranial nerves, fall of the upper eyelid, strabismus (often alternate strabismus) 
amblyopia, or diplopia more or less marked. These disturbances may, however, be but 
temporary. Besides these symptoms,' the first phase of the disease presents also troubles of 
the general sensibility, functional derangements of the genito urinary apparatus, partial 
paralyses, rarely hemiplegia. 

The troubles of the general sensibility consist in anaesthesia, analgesia, hypersesthesia 
and divers paresthesias. 

When the skin of the sole of the foot is affected with anaesthesia, the patient loses the 
sensation of resistance and of hardness in the ground on which he treads; he seems to him- 
self to walk on down or on soft and yielding earth. 

On the part of the genito-urinary apparatus, you may note retention or incontinence of 



ON THE TREATMENT OF CHRONIC MYELITES. 183 

which he described, indicates the little control which therapeutics has over this 
morbid condition, and in so designating it, Duchenne pronounces a sentence of 
incurability. Since then, therapeutics has not lifted this sentence, and it is best 
to bear in mind that this affection is almost always above the resources of our 
art. Nevertheless, ataxic patients have been cured, and are now being cured; 
but these are exceptional cases, and despite periods of calm and respite which 
may last months and even years, the ataxic individual sees his disease progress 
slowly or by bounds. 

These cases of cure concern more especially syphilitic patients. Without 
adopting altogether the opinion of Fournier, who will have it that all ataxic 
patients are syphilitic, it is nevertheless well to remember, that in a great num- 
ber of cases syphilis is the cause of tabes, and when the affection is taken at the 
commencement, an appropriate anti-syphilitic treatment may cure it. But it 
will not do to take for granted that it is always so; and in a great many in- 

urine (the latter generally nocturnal) satyriasis, then later, anaphorodisia and sometimes 
spermatorrhoea. 

The painful crises may affect the viscera and determine gastralgic paroxysms with 
vomiting, vesicular and urethral pains, or lumbar pain simulating renal colic. Fereol has 
remarked laryngo-bronchial troubles with spasm of the glottis and convulsive cough and 
hyperesthesia of the laryngeal mucous membrane. 

As for the second phase of the disease, it is characterized by the appearance of ataxic 
movements. The incoordination of movements is developed progressively, slowly, little by 
little, sometimes even insidiously. 

The ataxia begins in the lower limbs; the patient remarks first of all that he is very 
easily fatigued, that he cannot take long walks; then he observes that he is becoming clumsy 
in his legs, he stumbles and falls easily; it is difficult for him to start off when he attempts 
to walk, then after several hesitating steps he walks to better advantage. Later the incoor- 
dination makes progress, the patient cannot direct at will the force, the direction and the 
extent of his movements, he cannot take a step without looking at his feet; the leg is lifted 
up and then thrust forward with force and stamped on the ground heel first; he can no 
longer walk without a cane or some other support; in the night time the incoordination is 
still more marked, and walking and even standing becomes almost impossible. 

If a patient is lying down he performs quite easily the movements demanded, but 
sometimes he performs them too violently and overdoes it. 

The muscular force is intact, as one can convince himself by means of the dynamo- 
meter; coordination alone is wanting. 

Like phenomena may be observed in the upper limbs, and little by little manual exer- 
cise becomes impossible. 

Sensibility also presents disorders; diminution, abolition or perversion of the sensations 
of touch and of pain. Moreover, a notable retardation in the perception of an impression is 
observed. A patient, when pricked, does not feel the pain till four or five seconds later; there 
are mistakes of place, the ataxic with his eyes shut cannot indicate the point pricked. At 
the same time impressions produced by the contact of a cold body are more rapidly per- 
ceived, and the mistakes of place are less obvious. 

The sensibility of the muscles (the muscular sense), of the bones, of the joints, is equally 
affected, the patients lose the notion of position; that is to say, with their eyes shut, they 
cannot indicate the position of their feet in the bed. 

There are often observed at the end of the first period or beginning of the second, 
arthropathies, well described by Charcot, which occupy preferably the large joints, knee, 
hip, shoulders; the joints much swollen, puffed out by the liquid, are little or not at all pain- 
ful, and voluntary movements are made with difficulty, but only by reason of the swelling; 



184 ON THE TREATMENT OF CHRONIC MYELITES. 

stances in which, in syphilitic patients, there exists some form of medullary 
sclerosis, the most energetic and the most violent treatment will not favorably 
modify the march of the disease. However, the fact of syphilis coexisting with 
tabes dorsalis, always gives a hope and a chance for your patient, which you 
ought to improve. 

There are neuropathies which sometimes present ataxic symptoms; these 
false ataxies are often completely cured by hydrotherapy, or a course of treat- 
ment at the thermal springs. 

The first condition of treatment of sclerosis of the posterior columns, is to 
avoid all circumstances which tend to provoke congestion of the cord, a con- 
gestion which almost always precedes the hyperplasia of the neurolgia. You 
should then prohibit, in the case of these patients, prolonged muscular fatigue 
(a fatigue which is the more easily induced the more voluntary force the patient 
is obliged to expend in his movements) ; sexual intercourse ought also to be 
forbidden. You should also have recourse to energetic revulsion, and in par- 
ticular to punctiform cauterizations along the vertebral column, and this 
especially when signs of irritation or congestion of the cord appear. You can 
also use in the periods of remission nitrate of silver or phosphorus, following, 
in the case of phosphorus, the rules which I have laid down. You will almost 
always obtain with this phosphorus medication an amelioration, more percepti- 
ble to the patient than to yourselves; he will tell you that he feels stronger, and 
that he has a better command of his limbs, at the same time that an examina- 
tion does not disclose any real progress. I have never observed genital excita- 
tion following the administration of phosphorus, and I very much doubt the 
aphrodisiac properties which have been ascribed to this medicament. 

The lightning pains are among the most formidable complications of the 
disease; here our* "sheet-anchor " is hypodermic morphia, despite the fact that 
ataxic patients are very likely to become morphomaniacs (a great many at the 
present day are such). Sometimes extremes of temperature diminish notably 

at the end of a certain time, which is variable, destruction of the cartilages and bony tissue 
takes place. 

The reflex excitability of the cord is sometimes considerable in the ataxic patient, and 
the contact of a foreign body, especially of a cold object, on the skin produces reflex 
movements more or less extensive. 

Forced flexion of the foot on the leg, produces the phenomenon of reflex trepidation, 
so also does percussion over the tendo-achillis or the patella tendon, the latter giving the 
characteristic knee jerk. The " patellar reflex" is, however, often wanting. 

The trophic troubles observed in the course of the second period, consist in cutaneous 
eruptions, in emaciation of the limbs, atrophy of the muscles, and a rarefaction of the bony 
tissues which results often in fractures. 

Intellectual troubles are somewhat rare, at the same time there may be delirium 
more or less temporary, sometimes dementia. 

The motor incoordination makes progress; by and by the patient can no longer walk 
and is obliged to keep his bed. 

Every movement becomes impossible, and the paralysis invades progressively the 
upper limbs, sometimes even contracture of the affected members is noted (third period). 

Purulent cystitis, or incontinence of urine, or of fecal matters soon results in the for- 
mation of eschars on the sacrum, or in other regions and the patient succumbs. 



ON THE TREATMENT OF CHRONIC MYELITES. 185 

this pain; I have lately had under my care a French engineer, who, when con- 
structing railroads in Russia, could succeed in calming the douleurs fulgurantes 
of his disease only by surrounding his feet and legs with ice. In some patients 
heat has the same effect. In these cases Chapman's rubber bags for pounded 
ice or hot water will be useful. Nerve-stretching has been proposed for these 
douleurs fulgurantes? This elongation of the sciatic nerve, practiced for the 
first time in Germany by Langenbuch, in 1879, in France, by Debove and Gill- 
ette, in 1880, and since repeated by Esmarch, Erlenmeyer, Sury-Bienz, Hirsch- 
felder, Rzehaczek, has not given any definite results, and though causing a 
temporary amelioration, it is often accompanied by trophic disturbances of great 
intensity. Balneotherapy and thermal treatment have an important rsle in the 
therapeutics of ataxia. For my part, I have abandoned hydrotherapy in the 
treatment of medullary sclerosis. I believe that cold douches can only augment 
or provoke spinal congestions, and I am happy to see that most of my colleagues 
of the Society of Hydrology are of the same opinion. 2 

If hydrotherapy has rather inconveniences than advantages in the treatment 
of ataxia, it is not so with thermal treatment. Three stations claim preemin- 
ence, Neris, Balaruc, and Lamalou; the thermal establishments of the latter 
seem to be most efficacious in chronic myelitis. 

Finally, to these balneotherapic means we must add electricity. Onimus 
and Rosenthal have insisted on the curative action of continuous descending 
currents in the affections of the spinal cord. It is a means which you ought 
always to employ, without expecting always to obtain much amelioration. 

On the other hand, electricity has a preponderating role in the atrophic 
paralysis of infants, which, as the recent researches of Roger and Damaschino 
and of Laborde have shown, is to be attributed to central myelitis affecting the 
anterior horns, and destroying the large multipolar cells of that region. 3 These 

1 The first case of nerve stretching for locomotor ataxia was practiced in 1879, by Lan- 
genbuch; this operation was performed for the relief of the lightning pains, affecting chiefly 
the left sciatic nerve; this nerve was stretched on the 13th of September; the 25th of Sep- 
tember the right sciatic was stretched and the two crural; the pain disappeared completely, 
but afterward, in consequence of new pains appearing in the arms, elongation of the median 
nerve was attempted. The patient, unfortunately, died from chloroform during the opera- 
tion, January 6, 1880. 

Since then the operation has been performed by various surgeons — Esmarch, Erlen- 
meyer, etc. In December, 1880, elongation of the sciatic for the douleurs fulgurantes of ataxia 
was performed by Gillette under the direction of Debove. Gillette twice performed nerve- 
stretching for ataxia in 1881, and other continental surgeons have practiced in numerous 
cases of ataxia this elongation of nerves and with variable results. 

- Langenbuch, Berliner klin. Wochensch., No. 48, 1881. Esmarch, Deutsche med. 
Wochensch., 1880, No. 19. Erlenmeyer, Centrablatt fur nerv. und psych., No. 21, 1881. 
Debove. Gaz. des Hop., 11 Dec. 1880 Gillette, Union Med., No. 17, Jan. 1881. Sury-Bienz, 
Deutsch. med. Zeitung, 1881. Du traitement de l'ataxie locomotrice (Soc. d. hydrologie 
Med. Seance du 4 November, 1878. 

3 Infantile atrophic paralysis comes on generally between the ages of one to three 
years. Cases are exceptional after ten years of age. The mode of invasion is sudden, being 
announced by an intense fever, with or without convulsions. From day to day you observe 
paralysis develop sometimes general, affecting the upper and lower extremities, sometimes 



186 ON THE TREATMENT OF CHRONIC MYELITES. 

alterations have as a consequence the atrophy or destruction of important 
groups of muscles. Our only means of combating this disease are galvanism, 
gymnastics, and hydrotherapy, in a word, all these agencies which can excite 
nutrition in atrophied parts. These means have real efficacy only at the onset 
of the disease ; unhappily the first periods often pass unnoticed, and it is not 
till the later periods of the malady that our help is demanded, and then little 
can be done. 

The same treatment is applicable to a disease which resembles the atrophic 
paralysis of early childhood. I refer to progressive muscular atrophy, which in 
accordance with the pathological studies of the French school of medicine, and 
I refer particularly to the labors of Hayem, Vulpian, Troisier, Charcot, and 
Gombault, ought to be attributed, like the atrophic paralysis of early childhood, 
to chronic parenchymatous myelitis, localized in the anterior horns of gray sub- 



three members ; sometimes localized in a leg or an arm ; rarely it affects the two lower limbs 
only. This paralysis is at first complete, absolute, with flaccidity of the limbs. It often 
takes on the paraplegic form, but is not accompanied with sensory disturbances or functional 
troubles on the part of the bladder and rectum. 

Very rapidly, on the seventh or eighth day, Faradic contractility is lessened or abolished 
in a certain number of muscles, while galvanic contractility persists longer. The reflex 
movements are not always abolished from the first. From the second to the sixth month 
after the invasion, the paralysis abandons certain muscles, to localize itself in others ; mus- 
cles of the leg such as the peronei muscles and the anterior tibial ; notably the deltoid in the 
upper extremity. Then appear various special troubles : the atrophy, which according to 
Duchenne may already be very apparent at the end of one month, affects the muscles in 
which Faradic contractility is absent ; the bony system suffers an arrest of development and 
the bones of the affected side may be shorter than the corresponding bones of the healthy 
side. 

The side affected presents a remarkable lowering of temperature. The partial atrophies 
from which the patient suffers are followed by deformity of the limbs and determine vicious 
attitudes ; 'and it is in this way that club foot often takes its origin especially varus equinus, 
talipes valgus, and sometimes a deformity to which Duchenne has called attention, a sort of 
hollow-footed talipes, in which the forepart of the foot is hollowed out by exaggeration of the 
plantar concavity. 

In the upper limbs the most frequent deformity, sometimes only one observed, is 
flattening of the shoulder. You readily see the head of the humerus under the atrophied 
deltoid. In certain cases the arm hangs inert along the body, it is wasted, is much shorter 
than the other arm, the fingers are flexed on the hand which is itself flexed on the fore-arm. 

The prognosis, as far as life is concerned, is favorable ; from the point of view of 
function it is bad. The atrophy in fact is incurable and entails with it persistent infirmities. 

The anatomical lesions of atrophic paralysis of infancy are primitive and secondary, 
the latter consisting in trophic troubles of muscles, bones, and blood vessels. The primitive 
lesions consist in myelitis of the anterior horns of the cord, starting, according to Charcot, in 
the ganglionic cells. According to Roger and Damaschino the point of departure is in the 
blood vessels and neuroglia. In two autopsies of infants that succumbed to the disease, the 
one two months, the other six months after the commencement of the disease, they noted 
lesions localized in one of the anterior gray horns, consisting in inflammatory red softening 
with vascular injection and the production of granular bodies. 

According to Prof. Charcot, the nerve- cells are the first seat and origin of the irritative 
process, and there is produced an anterior acute parenchymatous, tephro-myelitis. 



ON THE TREATMENT OF CHRONIC MYELITES. 187 

stance. 1 In these cases 'constant currents applied methodically may have a 
happy influence. 

Such, gentlemen, are the principal considerations which I have to offer a 
propos of affections of the spinal cord ; you will find them quite incomplete, but 

1 Progressive muscular atrophy, so-called by Aran and Duchenne de Boulogne, has 
ordinarily a slow and insidious beginning. Without known cause, after a fatigue, a chill, 
the patients experience weakness in a limb. Then fibrillary contractions, independent of 
the will, occur spontaneously, are more or less frequent, and consist in slight starts or shocks 
of the muscular fibres. To these contractions, succeeds soon a loss of strength which attracts 
the attention of the patient. Then in the enfeebled parts is observed atrophy of the mus- 
cles, diminution in the volume of the part ; the muscular prominences disappear, and little 
by little with the progress of the disease all the soft parts seem to waste away and only the 
naked bones are left. As long as there are muscular fibres in a healthy state, electrical con- 
tractility remains, and it does not disappear till nothing is left but connective tissue. Du- 
chenne has remarked that along with the atrophied muscles there is lowered temperature 
and cutaneous anaesthesia. 

The disease, sometimes hereditary, more frequent in men than in women, seems to 
affect more particularly persons of adult age, and in full vigor ; it generally commences in 
the upper extremities, especially the right arm, and more frequently selects the right thenar 
or hypothenar eminences and interosseous muscles. 

The abductor brevis pollicis is taken first, then the other muscles of the thenar emi- 
nence ; the atrophy gaining rapidly, the muscular prominence disappears and the movements 
of the muscles becoming impossible, the antagonism exerted against the extensors of the 
thumb is destroyed, the first metacarpal bone is drawn backwards and outwards and the 
hand takes the aspect of a monkey's hand. When the interosseous muscles are taken, the 
spaces between the metacarpal bones sink in, the skin shrinks, and the hand seems deprived 
of flesh. 

The fore-arm is taken in its turn, and according as the atrophy affects the flexors, the 
extensors or the supinators, the corresponding muscular prominences are effaced. The 
muscles of the .arm, those of the shoulder, are stricken in their turn and disappear. The 
shoulder, is flattened, the head of the humerus and the acromion process are plainly visible ; 
when the fasciculi of the deltoid are invaded, the movements of the arm become impossible. 

In certain cases by the side of all the atrophied muscles, a single muscular bundle 
remains. 

Thus, in an observation of Duchenne, all the muscles of the hand and of the arm were 
completely atrophied with the exception of the supinator-longus which was intact. It is 
easy to understand the various deformities which result from these atrophies and from the 
vicious attitudes which the contractions of antagonist muscles, remaining intact, produce. 

The muscles of the trunk are next invaded, the atrophy gains the superior part of the 
trapezius, the pectorals, the serratus magnus and the respiratory muscles, even to the 
diaphragm and intercostals. These alterations entail important troubles in respiration, 
while atrophy of the muscles of the abdominal walls impedes the intestinal functions, mic- 
turition and defecation. The inferior extremities are ordinarily the last to be smitten, and 
those most often affected are the flexors of the foot on the leg, and the hip on the pelvis. 

In infants Duchenne has remarked that the atrophy instead of beginning by the upper 
extremities, begins by certain muscles of the face and the first affected is the orbicularis 
oris. 

The march of the disease is slow (from ten to twelve years) ; it may stop after having 
destroyed one or two muscles, but more often after a brief respite, the disease progresses 
anew. The patients succumb, either in consequence of affections of the respiratory passages, 
by exhaustion, or by reason of asphyxia caused by the penetration of food substances into 
the air passages (atrophy of the muscles of deglutition.) 



188 ON THE TREATMENT OF CHRONIC MYELITES. 

from a therapeutic standpoint they are necessarily so, by reason of their very 
incurability. These diseases of the spinal medulla, in fact, constitute the most 
gloomy chapter in therapeutics. 

To explain the phenomena of progressive muscular atrophy, three theories have been 
put forth : 

ist. That of Aran and Duchenne, adopted by Friedreich, which places the primordial 
seat of the malady in the muscles themselves which undergo degeneration. 

2d. The theory of Schneevogt which has been adopted by Jaccoud, which places the 
starting point of the disease in an alteration of the great sympathetic. 

3d. The theory of Hayem, of Charcot, of Vulpian, the theory to-day considered the 
most probable, which attaches this affection to the group of central myelites. 



PART SECOND. 

TREATMENT OF GENERAL DISEASES. 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

Summary. — Composition of the Blood — The Plasma — Its Alkalinity, its Composition — The 
Globules — The Red Globules — Haemoglobin — The White Globules — The Haematoblasts 
Enumeration of the Globules — Its Importance Therapeutically — Divers Methods of 
Enumeration — Hayem's Method — Qualitative Value of the Globules — Chromometric 
Process — Action of Medicaments on the Globules — Passage of Medicaments into the 
Blood — The Blood as the Vehicle of Medicaments — Modifications of Medicaments in the 
Blood — Direct Introduction of Medicaments into the Blood — Intra- venous Injections — 
Dangers of these Injections — Transfusion; History — Transfusion of Blood from the 
Animal to Man — Transfusion of Blood from Man to Man — Transfusion of Whole Blood, 
and Defibrinated Blood — Operative Procedure — Transfusion into the Arteries — Quantity 
of Blood Injected — Dangers of Transfusion — Results of Transfusion — Indications and 
Contra-indications — Injections of Blood in the Cellular Tissue — Injections of Blood in 
the Peritoneum — Intravenous Injections of Milk — Its Dangers — Intravenous Injections 
of Water and of Saline Solutions. 

Gentlemen — I propose to devote the present course of lectures to the 
treatment of general diseases. But first, in conformity to the plan which I have 
adopted, I must make some general remarks on the blood, considered from the 
standpoint of therapeutics. 

It may be said that, from the most remote antiquity, the blood has ever 
attracted the attention of physicians, and our ancestors, struck by the grave 
disorders which supervene as the result of haemorrhages, assigned to the 
sanguineous fluid the source of life itself. We see, in fact, this notion expressed 
in Leviticus xvii, 14: "The life of all flesh is the blood thereof." 

Since the time that Swammerdam, and especially Leuwenhoeck, discovered 
the blood corpuscles, making use of the new instrument which their fellow- 
countryman Zachary Jans, the obscure optician, of Middelburg, had just in- 
vented — thanks to that microscope which was destined to so profoundly revolu- 
tionize the study of the natural sciences — the number of works on hematology 
has been considerable. If I were to attempt to enumerate them all, it would 
take more time than I have to devote to this lecture. 

In this great scientific movement France has not been behind, and to the 
labors of Prevost and Dumas, of Magendie, of Andral and Gavarret, of Denis 
of Commercy, and of Claude Bernard, must now be joined the important re- 
searches of my colleague and friend, Professor Hayem, who has just published 
his remarkable work on the modifications of the blood under the influence of 
medicinal agents, a work to which I shall often have occasion to refer in the 
course of these lectures. 

At the same time, despite these so numerous researches, the study of the 
blood, especially from a therapeutic standpoint, presents still many obscure 
points ; and if we possess precise data concerning the anatomical and physiolo- 
gical constitution of this fluid, we are ignorant, in very many cases, of the modi- 
fications which it undergoes under the influence of medicines. 

The blood, this " flowing flesh " (chair coulante) of Bordeaux, and which 

191 



192 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

Claude Bernard has so well defined as the interior environment of the organism, 
presents two distinct parts, a liquid plasma and organized particles. 

This plasma contains, as you are aware, fibrin, albumen, water, salts and 
gases. 1 You know, also, that it is to one of the constituent parts of this plasma, 
the fibrin, that is due the phenomenon of the coagulation of the blood, although 
we are reduced to hypotheses to explain the mechanism of the coagulation. 2 
You know, also, that the plasma has an alkaline reaction, which it owes to salts 
of soda ; which, moreover, is constant and is found throughout the whole ani- 
mal kingdom. 3 This is a matter of prime importance, from a therapeutic point 

1 Davy, in 1799, extracted oxygen and carbonic acid from blood. Since the application 
of the vacuum, and the gas-pump of Ludwig, to this study, the analysis has been completed. 
According to all analyses, 100 volumes of arterial blood (of the dog) contain 22.2 volumes of 
oxygen at about the freezing point. This oxygen is intimately combined with haemoglobin, 
and the richer the blood in haemoglobin, the more oxygen it contains. 

One hundred volumes of arterial blood (in a dog) contain 33.3 vols CO s ; this gas 
comes from the serum. Schoeffer and Dreyer have shown that the blood globules have an 
action in the disengagement of C0 2 from the serum. 

The blood also contains a quantity of nitrogen. 

2 Several theories have been given to explain the coagulation of the blood. No one 
of them is without objection ; so much so, that it may truly be said that we do not yet know 
the exact cause of this coagulation. 

Denis conjectured that the plasma contains a special substance, plasmine formed by 
the union of concrete fibrine and soluble fibrine. When the blood leaves the vessels its plas- 
mine is decomposed and concrete fibrine is deposited. 

The plasmine, however, has never been isolated. 

In opposition to Denis, Schmidt has maintained that the fibrine which is deposited from 
the blood is constituted by two elements, fibrinogenous substance, and Jibro-plastic matter, 
which are contained in the blood in the living state and which, combining outside of the ves- 
sels, lead to the formation and deposition of fibrine. A ferment produced by the alteration 
of the globules is the efficient cause of this combination. This opinion has been vehemently 
combated by Hammarsten and others. 

Mathieu and Urbain consider the coagulation as produced by the fixation of C0 2 by 
tne fibrine. 

Gautier has shown that this theory is not exact since all it is necessary to do in order 
to retard the coagulation of blood is to add common salt to it, and yet the blood is not by 
this means deprived of its C0 2 . In fine Glenard in exposing blood plasma to C0 2 did not 
thereby produce coagulation. Mantegazza has maintained the opinion that the coagula- 
tion depends on the white globules. These globules in certain conditions set at liberty a 
substance which is the efficient cause of coagulation, if not coagulated fibrine itself. 

Albertoni has produced arguments in favor of this view. 

According to Hayem it is not the white globules but really the hematoblasts which play 
the active role in coagulation, and the phenomenon has for origin the physico-chemical 
actions which accompany the decomposition of the hematoblasts. (a) 

3 The serum of blood comes from the plasma after the coagulation of the fibrine. In 
man this serum is of a light greenish yellow color. The reaction is alkaline ; this alkalinity 



(a) Denis, Reckerches expe'rimentales sur le sang humain considere a V etat sain, Paris, 1830. Me'moire 
sur le sang, Paris, 1869, p. 32.— Schmidt, Chemis. central, 1861, p. 403 {Arch, fiir Anat. u. phys. 1851, 545 et 
675 ; 1862, p. 428,533 ; Arch, fiir pathol. anat., t. XXIX, p. 1).— Hammarsten, Arch, fur physiol., t. XVIII, 
p. 33, 1878.— Fredericq., Bull, de VAcad. roy . de Belgique, 2e sene, t. LXIV, n° 7.— Mathieu et Urbain, Acad, 
des sc, comptes rendus, t. LXXXIX, p. 665 et 698.— Gautier, Acad, dessc, comptes rendus, t. LXX, p. 1360.— 
Glenard, Bull, de la Soc. chim., t. XXIX, p. 511. 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 193 

of view, for all medicaments which do not possess this alkaline reaction, or 
which are unable to undergo, in the economy and before entering the blood, 
certain modifications converting them into an alkaline compound, cannot be- 
come an integral part of the circulating fluid, and can have but a local action. 

This predominance of the salts of sodium in the blood plasma explains why 
the sodium salts are better tolerated in the organism than the salts of potassium. 
This is a fact on which I insisted when speaking of the elimination of medicines 
by the kidneys, and I need only refer you to what I then said. 4 

The blood corpuscles play a preponderating role in the blood. Veritable 
travelling merchants of haematosis, 6 as Kuss felicitously calls them, they speed 
their way, carrying life to the most remote points of the economy. These 
globules present themselves, as you are aware, under three aspects — the red 
corpuscles, the white corpuscles, and the haematoblasts. 6 

is, however, less than that of the plasma and this results from the formation of a certain 
quantity of acid after the coagulation of the blood. The serum contains albuminoid sub- 
stances, fatty matters, extractive matters, salts and gases. 

a. Albuminoid Matters. — In the largest quantity and of the most importance, is the 
albumen of the serum, described under the name of serine. This serine when it is perfectly 
pure and deprived of salts, becomes cloudy at 6o° C, but its coagulation becomes complete 
between 73 and 75 . Besides this serine three other albuminoid substances are found in the 
serum: paro-globuline, described by Schmidt ; sertim caseine, which is only a combination of 
serine with soda (albuminate of soda) ; serum globuline, a proline body discovered by Denis. 

b. Fatty Matters. — Certain fatty matters have been found in the serum ; their propor- 
tion may be as high as 20 per cent. This quantity of fatty matters augments notably under 
the influence of a rich diet. Cholesterine is another constituent. Goblet and Hoppe Seyler 
have also found Iecithine, and Boudet has extracted from serine a crystallizable substance 
which he has designated under the name of seroline. This seroline is only a mixture of 
cholesterine and Iecithine. 

c. A saccharine matter is also found in normal serum. Claude Bernard has shown that 
it is a normal element of the blood even in carnivorous animals. This sugar is probably 
glucose or maltose and may be a mixture of both. 

d. Extractive Matters. — The presence of urea in the blood has been indicated by Picard. 
The proportion of urea rises during fever and falls during inanition ; uric acid and creatine 
have also been found in the serum. 

e. The most abundant of the salts of the serum is chloride of sodium; it exists in the 
proportion of five or six grammes to every thousand, that is to say, about %. per cent; then, 
next come the phosphates and in particular the alkaline phosphates. 

/. Gases. — The serum contains certain gases, and in particular C0 2 , N. and O. C0 3 
presents itself in the serum in three different states : in solution, in feeble chemical combina- 
tion, and in combination with soda. 

4 Chap. 1, Vol. II, The Kidneys from a Therapeutic Standpoint. 

5 Commis voyageurs de l'hematose. 

6 The white corpuscles or leucocytes are spherical and more voluminous than the red 
corpuscles. Their diameter is from 4 to 14 thousandths of a millimetre. But little is known 
of the condition of these globules, which are with difficulty separated from the red corpuscles. 
There is about 1 white to 350 — 500 red corpuscles : one cubic millimetre of blood contains 
8,000. The haematoblasts are very small bodies, about 3-1000 millimetre in diameter. 
They are colorless, and are discoid, biconcave like the red globules. They are in a marked 
degree susceptible of change, and after issuing from the blood-vessels they take on widely 
varying forms. These haematoblasts exist in the blood of all vertebrates. They give origin 

§13 



194 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

It was Hayem who first called attention to these last-named corpuscles, and 
pointed out their importance. These little bodies, very refractive and very 
alterable, are, in fact, red corpuscles in the process of formation; therefore, 
whenever it is necessary for us to study the renewal and regeneration of the 
blood, we ought to take great account of their number and their form. As 
for the red corpuscles, I can teach you nothing new as to their constitution. 
You are not ignorant of their form, their structure, or the important physio- 
logical role which they play. The haemoglobin which they contain gives to the 
blood its color, and as this haemoglobin has iron as one of its constituents, you 
understand the importance of chalybeates in impoverishments of the blood. 
This is, however, a more complex question than at first sight it seems to be, 
and will be more fully discussed hereafter, when we come to treat of anaemia 
and chlorosis. 

Do these blood globules undergo modifications in the presence of medi- 
cinal substances? This very important point is, unfortunately, not yet de- 
cided. , Binz, Kerner, Blake, and, more recently, Mayet, of Lyons, 7 have made 
numerous researches to elucidate this problem; but they have given us no posi- 
tive information, for their experiments were made with blood drawn from the 
vessels, and there is nothing to prove that the modifications in the form of 
the corpuscles, which these writers have described as being produced under 
the local action of medicaments, ever take place in the living subject. For 
my part, I am inclined to believe that, if we except the blood poisons, the 

to the red corpuscles. Their own origin is involved in obscurity. Hayem supposes them 
to originate in the lymphatic network. (Hayem — Researches on the Normal Anatomy of the 
Blood, p. 99.) 

1 Binz and Kerner have studied the action of the toxic and medicinal substances on 
the globules, and in particular on the white globules. Kerner mixed one part of a one-tenth 
solution of sulphate of quinine with four thousand parts of blood, and found that the globules 
changed their form and lost their movements. Blake injected into the blood sulphate of 
lithia, sulphate of thallium, chloride of rubidium, nitrate and acetate of silver. The sub- 
stances alter the blood globules, rendering them adhesive and thus causing fatal congestions 
of the lungs. 

Mayet, of Lyons, has studied the action of certain toxic and medicinal substances on 
the red globules. He takes one quarter of a milligramme of the substance with which he 
wishes to experiment, which he reduces to a fine powder and places on a glass slide; then 
he pricks the index finger of the left hand, obtaining a drop of blood with which he impreg- 
nates the medicinal substance; then he expels the air and lutes it with paraffine. 

It is thus that he has observed the action of chlor-hydrate of morphia, chlorhydrate of 
apomorphia, of narceine, of codeia, of basic sulphate of quinine, of basic brom-hydrate of 
quinine, of chlorhydrate of pilocarpine, of sulphate of atropia, and of the French and Ger- 
man digitalines. 

All of these substances have a double action, the one of solution of the globules, the 
other of deformation of the globules. With regard to the substances which produce 
solution of the globules, those most active are, first, the German digitaline, then sulphate of 
atropia, chlorhydrate of pilocarpine, brom-hydrate and sulphate of quinine. In a second 
category are placed bodies having a feeble and slow solvent action. In the order of their 
activity, these are, codeia, the French digitalines, chlor-hydrate of apomorphia and 
narceine. 

As for the alteration of the globules, this was the result of his observations: the French 






THE BLOOD FROM A THERAPEUTIC STANDPOINT. 195 

principal medicaments have little or no action on the red corpuscles or leuco- 
cytes. Take any animal, inject under its skin morphia, atropia, and most of the 
alkaloids, examine the blood, before, during and after the experiment, and it 
will be impossible for you to recognize with the microscope the least alteration 
in the globules of the blood. 

Fonssagrives believes that the globules charge themselves like sponges with 
medicinal substances, and that on arriving at the extremity of the capillary 
network they express into the serum the medicinal principle, in such a manner 
as to cause it to penetrate to the inmost recesses of the tissues. This is an 
hypothesis which has no inductive evidence in its favor, and it is more probable 
that the blood plasma alone serves as vehicle to medicines, (a) 

Be it understood that in this discussion I exclude those medicaments 
which, in depriving the red corpuscles of their respiratory power, despoil them 
also of their physiological function. You are all familiar with the interesting 
researches of Claude Bernard on the oxide of carbon. 8 We have here some 
interesting facts from a toxicological point of view, but which have no direct 
bearing on the therapeutic action of medicinal substances generally. I except, 
however, alcohol. I believe, and I insist upon it, that it is in depriving the 
globules of their oxygen that alcohol possesses antithermic properties. 

There are other medicaments which act on the blood corpuscles, either in 
destroying them or augmenting their number. I will revert to them when I 
come to speak of the action of mercury and of iron in syphilis and anaemia. 
The problem of their action is a difficult one to solve, for we are still ignorant, 
as physiologists, of the real origin of the red corpuscles. The labors of Hayem 
have shown that these corpuscles result from the evolution of the haematoblasts, 
but we do not know from whence the haematoblasts come. Is their source the 
marrow of bones, as the Italian and German schools teach ? Do they come 
from the lymphatics, as Hayem supposes ? We have only hypotheses to 
enlighten us, and this is why we cannot tell how the aglobular and hyperglobu- 

digitalines caused a granular transformation of the globules. Codeia, narceine, chlor-hydrate 
of morphia, and apomorphia occasioned a spheroidal deformation of the globules, with 
a period in which the borders of the corpuscles are prodigiously swollen. 

Sulphate of quinine transforms the globules into spheroidal elements but without 
previous swelling of their borders. 

According to Meyet it results from these experiments that from the point of view of 
physiological action, these toxic and medicinal substances influence the chemical molecular 
constitution of the organized albuminates of the economy. (6) 

8 The haemoglobin of the corpuscles has such an affinity for the carbon monoxide that 
the latter drives out all the oxygen and takes its place, forming a stable compound to the 
detriment of the organic combustions on which the vital processes depend. The globules no 
longer having the power of absorbing oxygen the animal on which the experiment is made of 
breathing the vapor of oxide of carbon, speedily dies asphyxiated. 



(a) Fonssagrives, Therapeutique generate, Paris. 1875, p. 170. 

(&) Kerner, the Lancet, 30 Janvier, 1872. Blake, on the action of inorganic substances when introduced 
directly into the blood. (Journal of Anat. and Physiol, No. 12., et Jour. Anat. and Phys., xiv.) Mayet, etud, 
sur 1' action de quelques substances toxiques medicamentenses sur les globules rouges du sang. (Arch de Phys. 
1883, t, ler, p. 374.) 



196 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

lar medicaments act (those that diminish and those that increase the blood 
globules), and whether they produce their destructive or reconstituent effect in 
the blood itself, or in the haematopoietic organs. 

But in order to understand this special action on the blood corpuscles, 
therapeutics is to-day in possession of very exact and very ingenious processes, 
which enable us to estimate with a considerable degree of accuracy, the number 
of globules in men and in animals, and, as these, processes are very easy of 
execution, everybody ought to be able to put them in practice. The most 
simple apparatus and the one the most in use is that of Hayem, which has 
replaced that of Malassez. 

This h se m at i- ¥ the examination of 

meter is composed jBKIiF t ^ ie ^°°d ]S t0 ^ e 

of a microscope to " made, the image of 

which is adapted a ■■ ' ■: ■ ■ - j| a square measur- 

glass side where into sixteen parts. 

The glass side has a ring one-fifth millimeter in depth cemented to its upper 
surface ; it is, of course, necessary that under the covering glass there shall be 
a stratum of the blood to be examined of equal depth everywhere. (Fig. 8.) 

Then you have two graduated pipettes. One is furnished with a capillary 
gutta percha tube (fig. 9, A). You prick with a pin the end of the finger, and 
immediately aspirate with this pipette two cubic millimeters of blood. With 
the other pipette (fig. 9, B), you take up half a cubic centimeter of artificial 
serum.' This serum you place in the little test tube C, and in this serum you 
deposit the drop of blood which you have just taken. By repeated aspirations 
in this mixture of artificial serum and blood you clean your pipette; then, after 
a homogeneous mixture has been effected by means of your glass spatula, you 
take up one drop on the end of your pipette and put it in the cell on the glass 
slide. 

When you apply your eye to the eye-piece and survey the microscopic 
field you will have an appearance before ycu like that of the following 
figure (fig. 10) and you will understand how easy it is to count the number 
of globules. As will be seen, each of the squares is divided in the mid- 
dle by a bar, which is alternately horizontal and vertical. The globules which 
are astride the lines which bound the great square, are to be counted 
apart, and the whole number divided by two before adding to the sum total. 

A very simple calculation, or what is more handy still, the examination 



1 This serum is made according to Hayem's formula as follows : 

3$ Chloridi sodii 1.00 gr. 

Sodii sulphatis 5.00 gr. 

Bichlorid. hydrarg 0.50 gr. 

Aquae dist 200.00 gr. 

M. This liquid serves for the enumeration of the globules in man. 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 



197 



of a table construct- 
ed for this purpose, 
will enable you, 
when once you have 
determined the 
number of globules 
in the square, to 
know the whole 
number of globules 
in a cubic milli- 
meter. 1 

If from a med- 
icinal point of view 
(as having a bearing 
on the action of med- 
icaments) it is often 
important to know 
the number of the 
globules, it is more 

The clinical 
methods are quite 
numerous and 
are almost all 
based on the 
chromometric ex- 
amination of the 
haemoglobin. I 
shall only refer 
to Hay em's 
method. In the 
employment of 
this test you have 
a glass slide, pre- 
pared for the pur- 
pose, with tWO Fig. io. 

equal quantity of water in both cells, and then 




necessary to be able 
to ascertain the qual- 
ity of the haemoglo- 
bin, the active prin- 
ciple of the corpus- 
cles. In the treat- 
ment of anaemia such 
quantitative analysis 
is especially neces- 
sary. I shall leave 
to one side the 
chemical method of 
dosage of haemoglo- 
bin, which is tedious 
and laborious, and 
briefly describe the 
clinical method, 
which is compara- 
tively simple. 

cells, separated 
from each other 
by a partition. 
These cells con- 
tain just two cu- 
bic centimeters of 
water. Then you 
require a little 
cardboard with a 
series of colored 
papers of various 
tints, each one 
corresponding to 
a given number 
of red globules. 2 
You p lace an 
with your pipette you take up 



1 The proportion of blood to artificial serum in the mixture is ascertained to be as I to 
248. A cube with sides 1 millimetre will contain 125 cubes of one-fifth millimetre. To find 
out the number of globules in one cubic millimetre of blood, multiply the whole number 
counted in the square of one-fifth millimetre depth, by 125x248, that is, by 31,000. 

2 This is Hayem's scale with the value in healthy blood globules of the different chro- 
mometric tints: 



Tint No. 1 8,649,000 globules. 

" 2 9,720,125 " 

" " 3 10,811,260 " 

" 4 11,892,375 " 

" 5 12,973,500 



Tint No. 6 14,054,625 globules. 

7 15,135,750 " 

"' " 8 10,216,875 " 

" " 9 17,298,000 " 

" " 10 18,379,125 " 



198 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

two to four cubic millimeters of blood and put it in one of the cells, the other 
containing only water. Then you pass, one after another, a series of colored 
papers under the cell which contains only the water and take note when the two 
tints (that from the cells containing the blood, and that from the cell under 
which you have the colored paper) are alike. You have then, thanks to the 
table which I have given you (and here you must be careful to divide the whole 
by the number of cubic millimetres which you have introduced), you have 
then before you the richness of the blood in hsemoglobine. A very simple cal- 
culation will enable you to estimate when once you know the number of the 
globules, the value of these in healthy globules. 1 

Behold then the physician armed with two clinical methods which demand 
little or no apprenticeship, and which are therefore available by all; rapid 

1 It will be seen that the chromometer consists of two parts; the first a glass slide in 
the middle of which are two cells, capable of holding rather more than 500 cubic millimetres 
of liquid; these cells are fixed side by side. Into one of these troughs a mixture of 500 cubic 
millimeters of water, with from two to ten cubic millimetres of blood is introduced, into its 
fellow an equal volume of distilled water only. The second portion of the apparatus is a 
series of small round discs of tinted paper, ten in number, each of which is attached to the 
centre of a slip of white card board. The color of these discs is made exactly to match with 
that of a series of standard mixtures of blood and distilled water, every one of which contains 
a known number of normal red globules. We place our glass slide over one of these discs in 
such a way as to bring the latter exactly under the trough filled with pure water; we then seem 
to have two solutions of haemoglobin side by side. When the tints are accurately matched, the 
optical illusion is well nigh perfect, and it is almost impossible to tell which trough contains 
the blood mixture, and which the water alone. 

At this stage of the process we have ascertained that the mixture of 500 cubic 
millimetres of distilled water with a measured volume of blood containing a known 
number of red corpuscles per cubic millimeter (for chromometry is always preceded 
by numeration) corresponds in depth with the tint of the mixture of the same 
quantity of water with a known number of discs. The latter figure is obtained 
from a table supplied with the chromometer. Supposing the corpuscles of the 
blood under examination to be functionally equivalent to normal corpuscles, i. e., con- 
tain an equal proportion of haemoglobin, the number of those in the mixture will be equal to 
the number represented by the colored disc, and their ratio will equal 1. This figure repre- 
sents the functional value of a normal corpuscle. Supposing the corpuscles under examina- 
tion to be impoverished, they will yield a tint equivalent to that furnished by a smaller 
number of normal corpuscles; the ratio between the figures will be fractional. An example 
will make the mode of calculation plain: Let us take a specimen of blood containing 
3,400,000 red corpuscles per cubic millimeter (the normal average is usually put at 5,000,000). 
We introduce 6 cubic millimeters of this blood, mixed with 500 cubic millimeters of water, 
into one trough, and find that the tint exactly matches that of the disc marked 2. On refer- 
ence to the table, we find that the disc represents the coloring power of 9,730,125 normal 
corpuscles. Accordingly we conclude that 3,400,000 x 6, or 20,400,000 of our corpuscles 
only contain as much haemoglobin as 9,730,125 normal globules. The functional value of 
each of our corpuscles, referred to unity as a standard, will therefore be represented by the 
fraction : 

-M22J2I _ . 14 8 

20,400,000 n 

The normal average of corpuscles per cubic millimeter is usually put at 5,000,000, in 
conformity with Welcker's estimate. (Contribution to Clinical Haemometry, by Baxter & 
Willcocks. London Lancet, June, 1880. Am. Reprint.) 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 199 

methods, and which require for their execution only a drop of blood. Remem- 
ber always that these two procedures should go hand in hand, and that a 
therapeutic result based simply on the enumeration of the globules is of very 
little value, for the reason that in order to appreciate the globular richness of 
the blood it is necessary not merely to know the number of the globules, but 
also their character, as determined by comparisons with blood that is perfectly 
healthy. 

Let us return to the subject with which we were occupied before this 
digression. I have told you that the blood serves as a vehicle for medicinal 
substances. Whether they undergo absorption by the pulmonary mucous 
membrane, by the stomach or by the skin, they reach in a short time the left 
ventricle of the heart, from whence they are sent forth to different points of 
the economy. In my lecture on the lungs from a therapeutic point or view, 1 I 
stated the circumstances which explain the greater or less rapidity of action of 
the medicament, showing you that this results from the time it takes the 
medicinal principle to reach the left ventricle. 

In order to render this action more speedy, it has been proposed to make 
the medicament enter the circulation directly, and intra- venous injections have 
been recommended. This is a deplorable procedure which should only be 
mentioned to be condemned, even from the standpoint of experimental thera- 
peutics; in fact, any results obtained in animals from such experiments are 
altogether untrustworthy. 

In fact, we have here superadded to the natural effect of the medicine a 
direct action on the blood which considerably modifies the symptoms which we 
observe. When we introduce a medicament by the digestive passages, by the 
skin or by the lungs, this medicament undergoes in some part of its transit 
between the point of absorption and the venous network, intimate modifications 
which for the most part escape us, and which enable it to traverse without 
danger the blood current. Is it the same when we mingle directly the 
medicinal solution with the blood in the veins ? Assuredly not; and this is so 
true that when, in administering hypodermic injections, 3^ou carelessly make the 
injection in a vein, you see supervene very grave accidents, however small the 
dose may have been. 

I am well aware that attempts have been made to bring certain of these 
intravenous injections into general practice, and we have seen Ore, of Bordeaux, 
propose to substitute for chloroform anaesthesia intravenous injections of 
chloral. The accidents which followed these injections caused them to be 
promptly abandoned, and even in cases of hydrophobia where they have been 
employed by Bucquoi, nobody now-a-days thinks of using them. 

It is of course understood that this absolute condemnation of intravenous 
injections extends only to medicinal substances. It is not so with the question 
of supplying to the blood or to the economy nutritive elements which are want- 
ing, and transfusion within certain limits is a justifiable and thoroughly rational 
therapeutic means. 

1 Vol. II. Lecture — The Lungs from a Therapeutic Standpoint. 



200 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

Transfusion originated in experimental therapeutics. This is a fact 
worthy of note, especially if you take into account the epoch in which it was 
first practiced. Indeed, before Denis, of Montpellier, the 15th of June, 1667, 
caused this operation to be performed by Emmerez, transfusing the blood of a 
lamb into a male patient, Lower, then King, had the year preceding shown that 
it was possible to transfuse the blood of one animal into another animal of the 
same or of a different species without any injurious results; from this date till 
the commencement of the present century transfusion like every other new 
therapeutic measure, was much abused, and it was imagined that all diseases 
including insanity could be cured by it, and it became even necessary to pass 
an act of parliament to oppose the misuse of the operation. 1 

From 1815 to 1830 transfusion issued from the oblivion into which it had 

1 Transfusion is of very ancient date, having been practiced centuries before the 
Christian era. It was not, however, till about the middle of the 17th century (1666) that the 
first scientific treatise on the subject appeared. It was the work of Lower, who put the 
artery of one dog in communication with the vein of another dog. King modified the ope- 
rative procedure of Lower, and using animals as the subjects of his experiments, made the 
transfusion from vein to vein, and practiced transfusion between animals of different species, 
as the calf and the sheep. In the same epoch Denis, of Montpellier, taking the previous 
experiments for his guide, caused transfusion to be performed on a man by Emmerez, June 
15th, 1667, making use for this purpose of the blood of a lamb. History has preserved the 
report of this case. The patient was a young man of sixteen attacked by a fever with stupor, 
and which was believed to be typhoid fever; he had been bled twenty times. Finally 90 
grammes were taken from him, and a transfusion was made of 270 grammes {9 fluid ounces) 
of arterial blood from a lamb; the patient got well. 

Lower and King shortly after reproduced in human subjects the therapeutic experi- 
ment of Denis and the operation from henceforth became very famous. In Italy, about the 
same date (1668), transfusion was practiced from man to man by Fracassati, Riva and 
Manfridi. 

It was proposed by these transfusions to modify the character of the blood, which was 
thought to be altered, and this method was applied to a great number of affections, and par- 
ticularly to madness. The operation speedily became abused and leagues were formed 
against it, and the intervention of legislation was sought; by an act of parliament the prac- 
tice was forbidden. Thus transfusion fell into disrepute and almost complete oblivion till 
the year 1825. Nevertheless, in 1788 there appeared the work of a physician of Modene, 
Michel Rosa, who had made numerous experiments on animals, transfusing the blood of one 
animal into an animal of another species. 

In 1815 this question was agitated again, and James Blundell counselled to employ a 
syringe to take up the blood and inject in the veins. Dieffenbach, in 1828, treats of two 
kinds of transfusions; immediate transfusion, when the artery of one animal communicates 
with the vein of another animal, and mediate transfusion, when a syringe is used. He was 
the first to recommend the use of defibrinated blood. In fine, coming down to our own 
times, since i860 this question of transfusion has been taken up anew, and not only has the 
manual procedure been perfected, but the numerous physiological problems presented by the 
operation have been studied, experimentally and physiologically, (a) 



a Blundell, Researches physiological and pathological on transfusion of bloody London, 1824. — Trans- 
fusion {in the principles and practice of Obstetric medicine, p. 209).— Dieffenbach, Die transfusion des 
blutes, Berlin, 1828, et trad, iafourn. complement, du Diet, des sc. med., t. XXXV, 1829.— A water, Zur Trans- 
fusion (Beitr&ge zur jeburtshulfe, and gyncekologie, t. II, gasc. 3, Berlin, 1875.— Gesellius, Die transfusion 
des blutes; eine historische, kritische, tend physiologische studie, Saint-P^tersbourgh et Leipzig, 1873.— Jen- 
nings, Transfusion. Its history, indications and modes of application, London, 1883. 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 201 

fallen; works appeared by Hufeland, De Graefe, De Boer, by Blundell and 
Bischoff especially, and the action of defibrinated blood was studied. Then 
transfusion fell again into neglect, to be taken up a few years ago at the point 
where it started, and while Ore, Gessellius, Hasse and Albins advise the direct 
introduction of lamb's blood into human veins, Landois, Panum, Ponfick, 
Albertoni, Beel and Kuster have pointed out the dangers of this practice. 1 

To-day, notwithstanding the efforts made by Roussel to perfect the instru- 
mental apparatus (which he certainly has modified in a happy manner) trans- 
fusion is an operation exceptionally performed, and there certainly are among 
you few that have ever been present at the operation. 

Nevertheless, this question of transfusion is one of the most important, and 
the recent researches of Hayem have enabled us to elucidate many obscure 
points. I shall then rapidly review this interesting topic, and I shall especially 
dwell on the three following points: the kind of blood which we ought to 
employ, the operative procedure which we should make use of, and the indica- 
tions and contra-indications of transfusion. Struck by the inconveniences and 
difficulties which often arise in the transfusion of human blood, the proper 
person from whom to obtain the blood not being always at hand; guided, 
moreover, by theoretical considerations which require that absolutely healthy 
blood should be used in the operation, certain physicians, in the early history 
of transfusion, made use of the blood of the lamb. You have seen that this 

1 Gessellius, in 1873, reverted to the procedure of Denis, of Montpellier, counselling to 
employ the blood of a lamb, not defibrinated. Hasse proposed and practiced the direct 
inoculation of lamb's blood, connecting the artery of the lamb with the vein of the man. 
He describes minutely the operative procedure. Ore is one of the partisans of the trans- 
fusion of lamb's blood. He pretends that such accidents as have been reported from the 
transfusion into the human subject of the blood of different animals are due to the too great 
quantity of blood introduced, or to the too great rapidity of the operation. He claims that 
the blood of animals is preferable to human blood for transfusion, and counsels transfusion 
in all desperate cases. At the same time, in the case of transfusion performed by Ore the 
individual succumbed, although only 35 grammes (or about an ounce) of blood had been 
injected; the death was by asphyxia. 

Hasse of Nordhausen, has practiced the transfusion of the blood of a sheep into the 
human subject 52 times, and has had but one unsuccessful case. 

Among these observations we shall cite the one which had for subject Dr. Redtel, of 
Cohen, a phthisical patient affected with dysphagia. The patient was slightly if at all 
benefited by the operation. 

Kuster, of Berlin, has taken a stand against transfusion, and in particular against 
transfusion of the defibrinated blood of the sheep. He has observed grave accidents after 
these transfusions. 

Brugelmann, of Cologne, on the contrary, affirms that arterial transfusions of lamb's 
blood, after Hasse's method, give excellent results in phthisis. 

Albertoni maintains that the transfused blood of an animal of the same species serves 
to form new blood, and constitutes a sort of sanguineous grafting. According to this 
authority the transfused blood of an animal of a different species is injurious, and such blood 
has toxic effects, (a) 



a Albertoni, Que devientle sang transfuse {Rendiconto delle recerche sperimentali esegulte nel gabinetto 
di fisiologia delle R. Universita di Siena, Milan, 1876). 



2G2 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

practice was revived in France latterly by Ore, and in Germany by Gessellius 
and Hasse, in Italy by Albini, and in America by Carl Proegler, but these 
transfusions were not always followed by happy results. There have been ob- 
served to follow them, fever, hematuria, albuminuria and even death.' The 
cause of these accidents has been indicated to us by the curious experiments of 
Landois and Ponfick, which have shown us the solvent action of the blood of 
animals of different species, the one on the other; and while Albertoni and 
Landois described the embolic infarctions noted at the autopsy, infarctions pro- 
duced by the agglomeration of heterogenous corpuscles, Biel gave us a chemical 
explanation of the toxic action of the blood of animals of different species, 
so that to-day this question seems to be definitely settled, and the trans- 
fusion of blood from animals to the human subject ought to be completely 
abandoned. Human blood, then, is the only proper material for transfusion. 1 

Here a discussion quite as important has arisen between the partisans of 
whole blood and those of defibrinated blood, and this question has been espec- 
ially the subject of labors by Professor Hayem. Some, as Claude Bernard, 
Magendie, Jullien, in France, Mittler, Demme and Madier, in Germany, have 
maintained that by defibrination you destroy the vital properties of the blood. 2 

1 Ponfick has made numerous experiments on transfusions. He has arrived at this 
conclusion that the foreign blood can be of no utility; it is even dangerous, he says, for it is 
immediately destroyed and the products of its destruction may have a toxic action. 

Landois has studied the action of the blood of different animals when transfusion is 
made from one species to another. He has injected the blood of mammals into the veins of 
frogs, the blood of hares into dogs, of dogs into cats, etc. He has shown that according to 
the animal experimented on, the globules injected are more or less rapidly dissolved. Dog's 
serum has the greatest solvent power; hare's is the least active. The globules injected pre- 
sent a variable resistance according to the species; those of the dog and cat are very refrac- 
tory, those of the hare dissolve rapidly, and when injected in a dog they disappear in a few 
minutes, and hsemoglobinuria, lasting several minutes, ensues. The globules of the animal 
under experimentation also undergo a certain solution. Thus the blood of a dog injected 
in a hare causes dissolution of the globules of the latter. 

Landois in a later work takes a positive stand against the transfusion into the veins 
of a human subject of animal blood, and explains the accidents which follow as resulting from 
embolic obstructions from the agglomeration of heterogeneous globules. 

According to Biel, sheep's blood is rich in alkaline, earthy carbonates and carbonate 
of soda, and when introduced into the blood of a man, it precipitates the earthy phosphates, 
causing embolisms, (a) 

2 Magendie, after bleeding animals and injecting their own defibrinated blood, always 
observed fatal accidents, and hence he opposed the defibrination of blood. Claude Bernard, 
Behier, and Jullien who considered this operation as unphysiological, have also maintained 
that defibrinated blood has lost its vital properties. This opinion has been supported by 
Mittler, Demme, Madier and Roussel. On the other hand Vorm Muller, who has made 
many experiments with defibrinated blood, counselled this defibrination as rendering the 
operation easier, the oxygenation of the blood more prompt, and as being opposed to the 
embolic accidents which supervene in consequence of the presence of clots. Casse maintains 



(a) Ponfick, Experimentelle Beitrage zur Lehre von der transfusion {Arch, fiir Path.^ Anat. und 
Fhys., t. LXII, p. 273). — Landois, Wiirdigung der Thieblut-trans fusion beim Menschen (CentralbL, 
1875, No. 1). — Transfusion mit dun Blute verschudener thierarten (Centralbl., 1874, No. 56, p. 883-885, 
897-900. 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 203 

Others, on the contrary, like Vorm Muller, Landois, de Christoforis, Casse 
and Hayem, have shown that defibrinated blood is not attended with the risk 
of embolism and the grave danger therefrom resulting, and that it possesses all 
the revivifying properties of whole blood, and promotes reconstruction of the 
blood when used in transfusion. Defibrinated blood may then be employed in 
transfusion, but in my judgment whole blood is preferable, especially if this 
transfusion be made without the possibility of admixture with air. If defibrin- 
ated blood does not " graft " well, whole blood on the contrary may be utilized 
in great part, and the experiments made by means of the apparatus of Roussel 
with whole blood show that the cipher of globules rises immediately after the 
operation, and that this augmentation is maintained for several days. 

It is well understood that when the question of the quality of the blood to be 
used is once decided, the transfusion is to be made in the veins and not in the 
arteries, although certain authorities as Hiiter, Petrognio and Wing claim good 
results in transfusing from artery to artery, alleging in favor of transfusing 
in this way that you thus escape the danger of pulmonary infarctions and 
especially the entry of air in the veins. By this method, however, you run 
the risk of obliterating the arteries; a greater pressure is demanded to cause 
the transfused blood to enter the circulation, and grave local disorders are 
likely to ensue. 

Progress in the manual procedure of transfusion has been especially 
in the direction of improvements in the instrumental apparatus, and to the 
pumps of Moncocq and Belina (more or less perfected by Charriere, Collin and 
Matthieu), which draw up the blood from vessels in which it has been exposed 
to the air to inject it in the veins of the patient, apparatuses have been substi- 
tuted which enable us to transfer the blood from one party to the other without 
any exposure to the air. To the simple gutta-percha tube, which Postempski 
and Luciani placed between the veins of the donor and the receiver, various 
agents of propulsion have been appended, and it is thus that are constructed 
the transfusion instruments of Schliep, Neudorfer and Roussel. The latter is 
the most complete, and I may safely say it is the one most in use at the present 
day. I show you here one of Roussel's instruments. It consists of a soft tube 
of caoutchouc, with an aspirating and force-pump, P, having a capacity of just 
ten grammes. This tube terminates at one extremity by two bifurcations, A 

a similar opinion. On his part Landois has shown that whipping (to remove the fibrine) 
does not destroy but a small quantity of globules, and Christoforis affirms that the globules 
all remain intact despite the whipping. Hayem has repeated all these experiments and he 
has shown that from an experimental point of view it is necessary to make a distinction be- 
tween defibrinated injections made with an animal's own blood, and those made with the 
blood of an animal of the same species. The former speedily entail diminution of the glob- 
ules and haematoblasts; injections made with the defibrinated blood of an animal of the same 
species energize the process of blood renovation, and the haematoblasts are observed to 
multiply prodigiously. (Jullien, These de Paris, 1875; Landois, on Transfusion of Blood, 
Leipzig, 1875; Behier, Revue Scientifique, 1874; Vorm Muller, Transfusion und Plethora, 
ect., Christiana, 1875; Casse, on Transfusion of Blood, 1874; De Christoforis, on Trans- 
fusion, etc., Ann. Univ. di Medicine Chir., Vol. 233-234, 1875; Roussel, on Transfusion, 
Arch. Gen. de Med., 1876.) 



204 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 



and A'. An ingenious stop-cock C enables us to send blood or water at pleas- 
ure into one or the other of these bifurcations. The most important part, 
however, is the cupping apparatus I V, which enables us to practice venesection 
with the lancet I, without the possibility of contact with the external air. This 
lancet terminates in a cutting-blade, like an inverted V. This cupping machine 
is placed over the vein of the donor of blood; the ball B is employed to exhaust 
the air, and the bell M, with the stop-cock C, is plunged into warm water. 




You will readily understand the way in which this apparatus is managed. 
The vein of the patient is first dissected out and well exposed. Then the cup 
is applied to the arm of the person who furnishes the blood, and right on a 
level with the point where the bleeding is to be practiced a stream of warm 
water is made to traverse the entire apparatus. A V-shaped incision is made 
in the exposed vein of the patient, and one of the canulas of the transfuser, full 
of warm water, is introduced and fastened into the vein; the communication is 
closed, a smart tap is given to the lancet I, the pump is worked, and presently 
there is seen to flow by the distal extremity of the apparatus, first blood 
mingled with water, then pure blood. At this moment you turn the stop-cock 
C, and the blood passes freely from one arm to the other. 1 

As to the quantity of blood to be transfused, this is very variable; it is im- 
possible to fix in advance the minimum figure. What we know is, that, from an 



1 Roussel makes many stages in the operation : 

First Stage — Get ready the vein of the patient. 

Second Stage — Fix a firm ligature above the elbow of the donor of blood; place the 
exhausting cup over the projecting vein, and arrange the porte-lancet, whose cutting blade 
must be regulated according to the depth you wish to penetrate. 

Third Stage — Pump up the water in order to clear the apparatus of air ; introduce the 
afferent canula, full of water, into the vein of the patient; close the canula; close the water 
aspirator (stop cock Ci). 

Fourth Stage — Give a smart tap on the head of the lancet ; the blood drives out the 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 



205 



experimental standpoint (as the curious experiments of Eulenbourg and Landois 
have shown), one may augment the mass of blood from 80 to 83 per cent, in 
animals without producing any accident, and that in clinical practice it suffices 
in cases of extreme anaemia, to transfuse very small quantities to restore the 
cardiac pulsations and bring the patient back to life. 

Transfusion is an operation which may be attended with accidents. 
Thanks to the very perfect apparatus of Roussel, we may avoid the gravest of 
these accidents, that is, the introduction of air into the veins and the produc- 
tion of emboli. There are, however, other accidents which are not so easily 
escaped. I refer particularly to the lesions of the vein in which is placed 
the transfusion- ^v^ canula devised 

canula. This is ^%JrV ^Y Istomin and 

one of the most ^S^^g^ti Welikig, phlebitis 

formidable parts /3&^3i^_________ ^*^&$0^ often occurs as a 

of the operation, ' i 'j^^^^ r "' ~~~~~z*^*'^ jfjl sequel of trans- 



and, notwith- 
standing the im- 
provements in the 




fusion. Some- 
times,moreover, it 
happens that the 

blood, instead of penetrating the vein, escapes into the cellular tissue, and pro- 
duces thromboses and serious displacements and lesions. These are, however, 
accidents that belong to every operation on the circulatory system, and they 
ought not to lead us to abandon transfusion. It is necessary, moreover, to bear 
in mind that there almost always comes on, after transfusion, a febrile 
paroxysm, characterized by chills, elevated temperature and profuse per- 
spiration. 2 



water, which presents itself, red, at the exit tube; close the exit tube, and open the afferent 
canula. 

Fifth Stage — Transfuse slowly, ten grammes at a time, five or six times a minute, till a 
sufficient quantity has passed. 

The dressing is simple enough, a figure-of-8 bandage being applied to the two arms. 

Roussel always takes pains, before the operation, to iscsehmiate the hand and forearm 
of the patient by a Martin bandage, and he afterwards puts a tight band around the middle 
of the forearm. (The bands above and below the elbow render the vein turgid, and prevent 
escape of much blood during adaptation of the canula.) He hooks up and opens the vein 
with scissors, making a flap like the letter V, then introduces and fastens the canula. This 
is kept in position by a serrefine. The two bands are removed the moment the transfusion 
commences. 

From a table published by Roussel, brought down to May, 1883, we find that he has 
performed transfusion 62 times; 33 of these were in surgical cases (traumatic, puerperal, 
chronic hcemorrhages, suppurations, pyaemia). Of these 33 cases, 24 are reported as 
successes, 7 as unsuccessful, and 2 as doubtful. Twenty-nine cases out of the 62 were 
medical (leucocythyaemia, chlorosis, inanition from dementia and other causes, cachexia 
from grave fevers, and blood-poisoning). Of these 29, 13 are reported as successes, 10 as 
unsuccessful, and six as doubtful (a). 

2 The fever after transfusion is due, according to Liebrecht, to stagnation of the blood 
in the venous system (Jour, des Sc. Med de Broux aller. 1875). 



(a) Roussel of Geneva, Direct transfusion of living blood. — (Gaz. des Hop, Feb. 18th, 1882). 



206 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

What results may you obtain from transfusion? To-day, thanks to the 
decisive experiments of Hayem, it may be affirmed, first, that defibrinated blood 
introduced into the organism, if it does not "graft" with the blood of the indi- 
vidual, nevertheless favors the renewal of the blood; secondly, that whole blood 
may be utilized in part, if taken from an animal of the same species. 

These scientific data enable us to judge the indications and contraindica- 
tions of transfusion. It is indicated in all cases of extreme anaemia, except 
where the economy is still capable of aiding in the renovation of the sanguine- 
ous fluid. Thus, according to Kuster 1 we should resort to transfusion in 
anaemia from haemorrhages, or other wasting discharges, in acute affections 
which threaten death by exhaustion, in curable affections of the digestive sys- 
tem, and he adds (though I do not agree with him) in septicaemia, and pyaemia. 
It is contraindicated in all cases where there exists in the organism an incurable 
lesion, directly affecting the constitution of the blood, and preventing its repro- 
duction. I believe, moreover, that it is useless, if not dangerous, in cases of 
profound cachexia, produced by cancer, advanced tuberculosis, and disorgani- 
zations of the kidneys. I would also not advise it in the anaemias called 
essential, to which I shall refer in another lecture, when the organism, smitten 
in the haematopoietic centres themselves, finds itself impotent to reconstruct the 
blood globules. On the other hand, in such cases as those mentioned above, 
where the patient is almost moribund from traumatic or post partum haemor- 
rhages, and from fibroid tumors, epistaxis, etc., I would resort to it, all other 
therapeutic resources having failed. 

You understand that I do not favor transfusion in general diseases and in 
most cases of blood-poisoning, such as pyaemia, septicaemia and all affections where 
microbes play a preponderant part. I make only one exception among the blood 
empoisonments; it is that produced by carbonic acid. It is easy to compre- 
hend how, in carbonic-acid poisoning, mortal accidents may be averted by sub- 
stituting living globules for globules smitten with death, and by favoring the 
renovation of these sanguineous elements. A great number of facts of this kind 
have been reported where, indeed, complete restoration has rarely been noted 
by transfusion, but where temporary amelioration has generally been obtained, 
as Traube, Wagner, Moller, Kuhn, Belfrage, Maurice Raynaud have shown. In 
a word, save in this particular case of blood intoxication, one cannot in general 
hope by transfusion to substitute healthy blood for vitiated blood, and this for 
the reason, to-day experimentally made certain, that whatever may be the opera- 
tive procedure employed, only an incomplete grafting of one blood with another 
blood can be obtained. 

Latterly in order to avoid the introduction of air in the veins, it has been 
proposed to inject the blood in the cellular tissue, or in a serous cavity, as the 
peritoneal; I avow that such procedures seem to me quite inapplicable to man. 
While recognizing the fact that subcutaneous injections of blood generally 

1 Kuster, Ueber die directe arterielle, thierblut-trans fusion {Arch. f. klin. chir., XVII, 
3e fasc, p. 384). — Panum, De Vindication et de la methede de la transfusion {Nordiskt 
medicinskt Arckiv., t. VII, no 3, 1875). — Casse, De la transfusion du sang {Mint, de 
VAcad. de med. de Belgique, 1874). 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 207 

undergo in the cellular tissue slow and progressive absorption, it seems to me 
difficult to believe that this absorption can be of any utility in the renovation of 
the blood, and I am of the opinion of Casse that these injections void of all 
therapeutic value, determine often grave local accidents. 1 

If we may rely on the experiments of Obolinski, Nikolski, Bizzozero and 
Golgi, intra-peritoneal injections of blood have in future a store of some 
promise. These experimenters have, in fact, always remarked in animals a 
rapid absorption of blood injected into the peritoneal cavity, corresponding to 
an augmentation in the number of globules and their richness in haemoglobin; 
but while admitting these facts as demonstrated, it seems to me difficult and 
impracticable to apply a procedure of this kind, as a therapeutical resource, to 
a human patient, especially when you reflect that for venous transfusion you 
are substituting the dangers of peritonitis, quite as serious as those of 
phlebitis. 2 

It is often difficult in transfusion to find the requisite blood and in suf- 
ficient quantity for the performance of this operation ; therefore of late years it 
has been proposed to substitute milk for blood. This is a modification of 
transfusion which Hodder, of Toronto, had already put in practice, in 1850 in a 
case of cholera, and which Howe, of New York, employed in 1877 in cases of 
phthisis. It is, however, especially Dr. T. Gaillard Thomas who gave popular- 
ity to this method, which he considers superior to the tranfusion of blood. 3 

One cannot protest too strongly against such affirmations. Not only are 
injections of milk useless as far as renovation of the blood is concerned, but 
they are injurious and dangerous. The experiments of Brown-Sequard, of 
Laborde and of Culcerq are absolutely demonstrative of this, and the cases of 
death which have happened during these injections confirm in every respect the 

1 Casse, on the Value of Subcutaneous Injections of Blood, Bull, de 1. Acad. Med., 
Belgique, July, 1879. 

2 Vide Bizozzero and Golgi, Transfusion of the Blood into the Peritoneal Cavtiy 
(L. Observatore, Nov. 4, 1879, p. 689). Obolinski, Experimental Researches on Peritoneal 
Transfusion (Centralblatt, f. Chir., No. 19, 1880). Nikolski, Influence exerted by Trans- 
fusion of Blood into the Peritoneal cavity, on the number of blood corpuscles and the 
quantity of haemoglobin contained in the blood in circulation (Wratsch, 1880, No. 4.) 

3 Hodder, of Toronto, in 1850 performed the intra venous injection of milk in a 
patient affected with cholera. Howe, of New York, in 1877 practiced these injections in a 
case of phthisis in the last stage; he injected 200 grammes (over six ounces) of goat's milk 
into the cephalic vein. Dr. T. Gaillard Thomas has practiced the intra- venous milk injec- 
tions twelve times, and has had but one case in which any accidents occurred. The milk 
should be drawn just at the moment of the operation, and not more than eight ounces 
should be injected at one time. These injections are especially applicable to cases of grave 
hemorrhage, Asiatic cholera, typhoid fever and pernicious anaemia. Thomas considers 
these injections infinitely easier of administration than those of blood. Wm. Pepper has 
also performed these transfusions of milk in two cases ; in one of these the patient died 
suddenly during the third injection. He concludes, however, that these injections of milk 
give results as satisfying as those of blood. He does not think that there is any danger of 
embolism. Brinton is of the same opinion. Brown-Sequard considers these lacteal trans- 
fusions as of considerable utility. In his estimation the morphological constitution of the 
figured elements of the blood plays a secondary r61e in the phenomena of transfusion. 



208 THE BLOOD FROM A THERAPEUTIC STANDPOINT. 

experimental data, showing us that milk corpuscles act in these cases by deter- 
mining emboli, which are generally fatal. 

In fine, it has been proposed in certain cases to inject into the blood prin- 
ciples which are lacking in that fluid. Thus, in cholera, where the symptoms 
of algidity are produced by the elimination of serum in great quantity in the 
stools, injections of water and of serum have been made. I myself put in 
practice this method in the epidemic of cholera which I was enabled to observe 
in 1872 and 1873 at the Hospital Beaujon, thus renewing a practice which was 
employed during the first outbreak of cholera in Europe in 1830 by Jachnichen, 
of Moscow, and in 1832 by Latta, of Scotland, and by Magendie the same year 
in France. 4 

Less successful than Lorain, who, during the epidemic of 1868, obtained in 
this very hospital (St. Antoine) a single cure from these intra venous injections 
of saline solutions, I have been able to realize only a temporary amelioration, 
and I believe that this results from the difficulty we meet with in the construc- 
tion of an artificial serum. In fact, in spite of the complex formula of this 
solution which I used, I could not prevent the dissolution of the blood globules, 
nevertheless I persist in believing that in the final periods of cholera these in- 

Culcerq has experimented on animals with the intra-venous injections of milk. He has 
shown that these injections may be often dangerous, and that the accidents observed are to 
be attributed to fatty embolisms (a). 

4 Saline solution of Dujardin-Beaumetz for intravenous injections in cholera, founded 
on the analysis of blood serum by Dumas: 

Distilled water 1000.00 gr. 

Chloride of sodium 3. 10 gr. 

Phosphate of sodium o. 50 gr. 

Carbonate of sodium 

Sulphate of potassium 

Lactate of sodium aa 1.00 gr. 

In making these injections all that is necessary is a syphon, terminated by a fine 
metallic tube which is introduced into the vein. 

[The solution for intravenous injection of Hayem is as follows (Gazette Medicale de 
Paris, September 13, 1884): 

1$ Water. . 1.000 

Chloride of sodium 5 

Hydrate of sodium 5 

Sulphate of soda 25 

M. It is, according to Prof. Hayem, advisable to inject a quart of this solution. It is 
especially recommended in the algid stage of cholera.] 

(Dujardin-Beaumetz: " Intravenous Injections of Water and Saline Solutions in the 
Treatment of the Period of Algidity of Cholera." Union Medicale., 1873) 



(a) T. Gaillard Thomas: "Intra venous Injections of Milk as a Substitute for the Transfusion of Blood," 
N. Y. Med. Jour., May, 1878, Bullard : " A Successful Case of Intra venous Injection of Milk," N. Y. Med. 
Jour., April, 1878. Pepper : " On the Intra venous Injection of Milk in Functional and Organic Anaemias," 
Med. Record (New York), Nov. 16, 1878. Brinton in N. Y. Med. Record, Nov. 2, 1878. Howe in the Medical 
Record, Dec. 7, 1878. Brown-Sequard : " On Transfusion of Milk in the Human Subject," Gazette Med. de 
Paris, No. 43, 1878. Culcerq : " Experiments on the Intra venous Injections of Milk," These de Paris, 1879. 



THE BLOOD FROM A THERAPEUTIC STANDPOINT. 201) 

jections may render service, and even result in recovery. Quite recently Jen- 
nings has taken up these intra-venous injections of saline solutions and has 
endeavored to bring them into general use. 1 

Such are the considerations which I desire to present a propos of the blood 
from a therapeutic standpoint, but I have only unfolded a part of my subject in 
this lecture. It remains to examine what happens when blood is removed from 
the economy, that is, to study the role of blood-letting in therapeutics, which 
will be the subject of my next lecture. 

1 O. Jennings, On Transfusion, London, 1883. 

[Recently the subject of intravenous saline injections has been brought prominently to 
notice by Szuman, in Berliner Klin. Woch., and Bischoff (Bull.Gen.de Ther. t cv, p. 190 q.v.) 
Szuman's case was that of a boy set. 15, who had sustained a compound fracture of the 
humerus, and fractures of the right femur and tibia. When seen he was in a state of col- 
lapse, the face, lips and conjunctiva bloodless, and he was almost pulseless. Resection of 
the humerus was performed; the collapse became so great that artificial respiration was re- 
sorted to; food and stimulants could not be given by the mouth on account of vomiting. As 
the patient seemed to be dying of cerebral anaemia, intra venous injection of saline fluid was 
made — 3 iss common salt, gr. xv of carbonate of soda in § xxxivss of distilled water. The 
saline solution was injected by means of a simple extemporized apparatus of gutta percha, 
with a syringe and canula. After § xxiv were injected the pulse fell from 144 to 112 and he 
began to complain of feeling cold; the injection was discontinued and the ligature removed 
from the vein. From this time he steadily improved and finally completely recovered. — Med. 
News, August 18, 1883. 

The case of Dr. Bischoff' s was one of postpartum haemorrhage with complete collapse, 
An injection of 200 grammes of a six-per-cent. solution of common salt was made into the 
peripheral extremity of the divided radial artery. The solution was rendered alkaline by 
the addition of two drops liquor potassae. Amelioration was immediate and recovery com- 
plete. It would seem from these experiments that the benefit derived from transfusion is 
largely, if not chiefly, due to the restoration to the circulation of its quantitative equilibrium, 
and that weak saline solutions are the best for this purpose. Still more recently remarkable 
instances have been recorded by Mikulicz of Cracow, and Fox of Laibech, in which life 
was saved after very profuse haemorrhages by intra venous injections of common salt solu- 
tion; in one instance twenty ounces, in another eight- and-a-half. Wikulicz's solution con- 
sists of: one part carbonate of sodium, six parts of common salt, and 1,000 parts of thoroughly 
boiled water, injected into the medium basilic vein. He used a funnel with rubber tube 
attached to the canula. — Trans.] 
i!4 



ON BLOODLETTING. 



Summary — Bloodletting — History — Popularity and Decadence of Bloodletting — Divisions 
— Local Bleeding — General Bleeding— Arteriotomy — Phlebotomy — Manual Procedure 
of Bleeding — Experimental Researches — On the Influence of General Bloodletting — 
Action on the Blood — Modifications of the Globules — Modifications of the Serum — In- 
fluence on the Circulation — Modifications of the Pulse — Modifications in the Speed of 
the Circulation — Modifications of the Mass of Blood — Modifications of the Blood 
Pressure — Influence on the Respiration — Influence on the Nervous System — Influence 
on the Nutrition — Conclusions — Therapeutic Applications of Bloodletting — Local 
Bleeding by Cupping — Leeches — Artificial Leeches — Mode of Application — Physiologi- 
cal Effects — Therapeutical Applications. 

Gentlemen : From a medical point of view there is no history more inter- 
esting alike to philosopher and physician than that of bloodletting. It is a 
history replete with useful lessons. We see there illustrated the truth that when 
the spirit of system and of routine takes possession of a philosophical or medi- 
cal doctrine, the results are distorted and misinterpreted, and the practical out- 
come is barren of good fruits and baneful. If, moreover, the word of the mas- 
ter is worthy of respect, hot-headed enthusiasts who urge to riot and madness 
every good measure are always to be distrusted ; finally, enlightened observa- 
tion and the true scientific spirit ought continually to submit to the test of the 
experimental sciences the data furnished by tradition. 

We are ignorant of the origin of bloodletting ; we only know that it was 
in use at the dawn of our historical era. Eleven hundred years before Christ, 
Podalirius is said to have practiced it at the siege of Troy. It is probable that 
it was already in vogue among nations where civilization was more advanced, 
and that in Egypt, India, and China bleeding was a recognized therapeutic 
measure. 

However this may be, Hippocrates, in his writings, speaks of bloodletting 
and its indications. Afterwards Aretseus and especially Galen insist on the 
importance of bleeding, and thenceforth down to the seventeenth century vene- 
section was practiced in accordance with the principles which Hippocrates and 
Galen had laid down. It was as much as ever, if during this long space of 
time certain opponents, Van Helmont and Porcius in particular, dared lift their 
voices in protestation against the abuse and the uselessness of bloodletting. 1 

1 The following passage from one of the writings of Hippocrates makes particular 
mention of bloodletting : " A patient had borboygmi and pain; had taken emetics without 
relief ; was bled by turns from each arm to syncope, and got well." 

From the time of Hippocrates, bloodletting has given rise to very many discussions ; 
nevertheless, owing to the influence of Galen and Celsus, who were for ages the teachers in 
medicine, bleeding was adopted as a treatment applicable to a great number of complaints. 
Galen made the following reservation : not to bleed children under four years of age, and 
rarely to bleed old people. 

It was in the seventeenth century that the contest between the adversaries and the par- 

210 



ON BLOODLETTING. 211 

They were, however, little heeded, and the majority ranged themselves on 
the right side of Botalli, who compared diseased blood to stagnant water in a 
well, which becomes more and more pure the more you take out. It is pre- 
cisely so, said Botalli, with the blood and with bloodletting. 2 

It was, however, in the seventeenth century that phlebotomy attained its 
zenith, becoming in France, as in England, the unique system of treatment of 
all diseases — children and old men alike were bled; the newborn babe even was 
not spared, and blood was taken by quarts. Guy Patin bled his confrere and 
friend Mentel thirty-six times in succession, and caused himself to be bled seven 
times for a simple cold. Pitcairn drew more than five kilogrammes from a 
rheumatic patient, and Gregory, for a pleurisy gave issue to more than six 
kilogrammes. Medicine at this epoch was reduced to these three great ele- 
ments: purgings, bleedings, and clysters; and the response of the bachelor in 

tisans of venesection took on the most vehemence, and a perfect furor for letting of blood 
seized certain physicians. Guy Paton was the most ardent of these enthusiasts. He bled 
his confrere Mental thirty-two times consecutively, and bled himself seven times for a cold. 
He would bleed infants at the breast, and even aged people. 

Chirac went further, if possible, than Guy Paton, and to him is ascribed that celebrated 
utterance, " Small-pox, I will make you used to the lancet." 

Pitcairn boasted of having drawn twenty English pounds of blood from a patient 
affected with acute articular rheumatism. 

Tweedie, in a case of pericarditis, took first 421 grammes, then 720 grammes, then 
960, then 1200, and finally 1440, before the patient was relieved. 

Gregory caused a pleuritic patient to lose 5520 grammes in the course of several days. 

There was a revival of excessive bleeding under the influence of Broussais at the be- 
ginning of this century, and Bouillaud, with his bleedings, "blow after blow" {coup sur coup), 
was the last representative of this period, which Schneider has characterized as the period 
of hcematomania. 

The ancients practiced phlebotomy with various instruments; generally a spear-pointed 
fleam, called fossoriwn, was thrust into the vein. This instrument is still used by veterinary 
surgeons when they bleed horses. One of these fossoria was found in the ruins of 
Pompeii. 

They also used an instrument called scalpellus, with which they opened the vein. 
Galen employed a cutting implement which he described under the name of phlebotomon. 
Albucasis made use of all three kinds, the scalpellus, the fleam, and the phlebotomon. 

The words lance and lancet were not introduced into surgery till about the year 1200. (a) 

5 Botalli was a physician of the University of Paris; afterwards (from 1571), Physician 
to Charles IX. His controversy with the faculty, and in particular with Donatus, has be- 
come famous. The latter reproached him with the hardihood of his bloodlettings. He was 
one of the greatest partisans of phlebotomy. He bled all his patients to excess, basing him- 
self on the principle which he enunciated to his friend Etienne Pasquier: "The more you 
withdraw of stagnant water from a well, the more of pure water flows in to take its place. 
The more the wet-nurse is sucked by the infant, the more milk she has; the like holds good 
with bloodletting." (0) 



(a) Journal, Considerations Relative to General Bloodletting, 1867. Brichetau, Bloodletting, Its Physio- 
logical Effects and Therapeutic Indications, Bull, de Ther., lxxv. p. 261, 1868. Article Saignee, in Diet. En- 
cyclop, des Sciences M6d. Saucerotte, Bull, de TheY., li., p. 145. 

(<5) Etienne Pasquier. Lettres liv. xiv., lettre 19; Botalli, " On the Cure of Disease by Bloodletting, in- 
cluding- the Opening of Veins, Scarifications of the Skin, and the Application of Leeches." Antwerp, 1583. 



212 ON BLOODLETTING. 

the immortal comedy of the Malade Imaginaire is in exact conformity to the 
prevalent practice of the epoch, when he replies to all the questions propounded 
to him by these three lines : 

Clysterium donare, 
Postea seignare, 
Ensuita purgare. 

When one thinks of the prodigious number of purges ordered, the enor- 
mous quantity of lavements administered, and the sanguinary floods which 
phlebotomy produced in this and the succeeding epoch, one can but exclaim 
with Bouley, physician to the hopital Necker, in view of such heroic medica- 
tion: "A sick person has more vital resistance than one would think !" 

This mania for bloodletting, after having abated for a number of years, 
burst forth with new ardor at the commencement of the nineteenth century, 
and Bosquillon with his humoral ideas, Broussais with his physiological 
doctrine, Bouillaud with his system of bleedings, blow upon blow (coup sur 
coup), gave a new eclat to the practice of phlebotomy. Then the zeal by 
degrees died away again, and it may be truly said that to-day the prescription 
of a phlebotomy is an exceptional thing in the practice of our hospitals, and it 
is as much as ever if I order one or two bleedings a year. Peter has indeed 
made some attempts the last few years to show the evil consequences of so com- 
plete an abandonment of this therapeutic measure. We will now see by the 
most recent data of experimentation, if the favor which bloodletting once found 
and its present abandonment, are susceptible of justification. 

We purpose here to divide our subject into two parts, and study in particular 
the action of general bloodletting, and that of local bloodletting. We purpose 
also under each of these heads to examine successively the operative procedure, 
the physiological effects, and lastly the indications and contra-indications of 
general and local bloodletting. 

General bloodletting (called also venesection, phlebotomy) is practised, as 
you know, at the bend of the elbow; and although in my audience there are 
doubtless many who have never bled a person, or seen one bled, I need not 
now take up your time in describing the operation, which you will find in full 
detail in any text-book on minor surgery. 7 This ignorance of the manual pro- 

1 Bloodletting has been practised from quite a number of vessels. Galen Hippocrates and 
Celsus bled from the veins of the nose; Rhazes and Avicenna selected the veins of the 
tongue, a kind of phlebotomy still practised in veterinary surgery; in fact, blood has 
been taken from almost all of the superficial veins of the body. To-day bleeding is 
practised exclusively at the bend of the elbow. Various instruments have been devised for 
bloodletting; the Germans still use mechanical phlebotomes which consist of a metallic box, a 
graduated lance, and a spring. 

The vein at the bend of the elbow which is generally selected for venesection is the 
median cephalic, and this is generally preferred because the median basilic passes over 
the brachial artery. This is a very important relation and explains those unfortunate cases 
where bloodletting has resulted in aneurismal varix. 

To cause swelling of the veins, a ligature or tight bandage is made to encircle 



ON BLOODLETTING. 213 

cedure is quite pardonable in anybody, considering how very seldom bleeding 
is practiced in even our large hospitals. 11 

What are the physiological effects of bloodletting ? Here we have to study 
the effects of bleeding on the circulation of the blood, and on the blood itself, 
and the modifications which supervene in the functions of the different organs 
of the economy. 

The blood is profoundly altered by bloodletting, and we must examine 
successively the modifications of the globules, and of the serum. In treating 
the globules, we are to consider the changes in the red corpuscles, the leuco- 
cytes, and the hsemaloblasts. 

Hayem has shown us in his admirable work on the modifications of the 
blood, from which I derive the principal data of this lecture, that every loss of 
blood, however trifling, and though not exceeding 1.75 per cent, of the weight 
of the body, produces a diminution in the number and quality of the globules 
which persists from ten to twenty days. 3 When the hemorrhage is large, or 
when the bleeding is often repeated {coup sur coup), the diminution of the 
globules continues and even augments during the eight days which follow the 
operation. But that which it is important to note, is that in proportion as 

the arm above the elbow, the forearm is rubbed vigorously upward, the patient being in- 
structed to shut the fist firmly; then, when the veins are sufficiently distended, the operation is 
performed. 

The operator takes the forearm in his hand, places his finger on the vein a little below 
the place of the intended puncture, and then (using the right hand for the left arm and vice 
versa) pushes the lance obliquely into the vein and makes it cut its way directly outward. 
When enough blood has been taken, the surgeon should untie the ligature above the elbow 
and place his thumb over the bleeding aperture. He should then put a small piece of lint 
on the wound and secure it with a strip of plaster; over this he should put a square com- 
press of linen and over the whole a figure of eight bandage. 

Bloodletting is generally a very simple operation, nevertheless it sometimes presents 
great difficulties, resulting from the corpulence of the patient and the depth to which it is 
necessary to make the incision. These difficulties are enhanced if the patient proves re- 
fractory during the operation. 

The accidents which may accompany venesection are numerous; the most grave of all 
is puncture of the brachial artery; sometimes there follows abcess in the areolar tissue, or 
even phlebitis; the latter resulting from the carelessness of the operator in using a foul 
instrument or from the fact of the operation itself, however carefully it may have been 
performed, (a) 

2 Phillipart, of Tournay, has protested against the abandonment of bloodletting. He 
insists that the profession, in forsaking venesection, has gone too far, and that it is 
needful to return to this ancient mode of treatment in acute diseases. Apropos of the 
neglect of bloodletting, he cites some curious facts — namely, that the physicians of hospitals 
attached to the Central Bureau in the year 1867 prescribed bleeding but twice out of 8000 
consultations, while in 1852 it was prescribed 1259 times, (o) 

3 According to Hayem, a single emission of blood not exceeding 1.75 of the weight of 
the body, produces a slight degree of anaemia and a reduction in the number of globules 



(a) Vide Chelius Surgery (South's ed.) vol. iii ., p. 609. 

(b) Phillipart, On Bloodletting- in the Treatment of Acute Diseases. Bull, de l'Acad. de Med. de Belgique, 
1883, t. xvii, p. 128. 



214 ON BLOODLETTING. 

the globules are destroyed, others are produced with extreme rapidity. The 
number of the hsematoblasts also augments after each bleeding, and in a 
marked manner; this it is which has led Hayem to say that every hemorrhage 
inevitably causes a hwnatoblastic crisis. This reproduction is even so rapid in 
certain animals, as the dog, that it is difficult to produce in them a persistent 
anaemic state by bleedings of moderate intensity, even if frequently repeated. 

As for the leucocytes, Weber and Bauer maintain that they augment with 
losses of blood ; Hayem affirms, on the other hand, that it is not so, and that 
their number remains the same after as before the emission of blood. 

The modifications effected in the blood-plasma are less known than those 
of the globules. Thus, while Prevost, Dumas, and Jiirgensen allege that there 
is augmentation of albumen, Becquerel and Rodier maintain that there is 
diminution. There is the same dispute with regard to the fibrin ; White, An- 
dral, Gavarret, Schutzenberger, Nasse, Sigmund, Mayer, Jiirgensen, assert that 
fibrin is increased ; Magendie, Coze, Hirtz, Briicke, affirm a decrease ; Hayem 
is of the opinion of the first-mentioned experimenters, and according to his 
numerous researches there is a positive increase of fibrin after each blood 
letting. 

As for the plasma, note that Arsonval has always found peptones in the 
serum after copious bleedings ; this is a fact of great importance, and shows the 
modifications affected in nutrition by phlebotomy, the peptones being the result 
of a veritable autodigestion provoked by each bleeding. 4 

which persists from ten to twenty hours. When the hemorrhage is large a much more 
marked diminution in the red globules follows, and continues for several days. 

In the dog it is difficult to cause any great degree of anaemia by bloodletting, and 
you cannot reduce the number of globules below 200,000 without producing death. 

In the dog, moreover, reproduction of the red globules is effected with great rapidity. 

Bloodletting, according to Hayem, is always attended with augmentation in the 
number of haematoblasts, what he calls a "haematoblastic crisis " resulting. 

4 Bleeding modifies the blood -plasma. We have few precise data respecting the modi- 
fications effected in the proportion of albumen. 

According to figures given by Prevost and Dumas, there is augmentation in the quan- 
tity of water and albumen. 

Jiirgensen also found increase of albumen while Becquerel and Rodier report diminu- 
tion. 

As for fibrine, there are two contradictory opinions, Andal, Gavarret and Schutzen- 
berger, have maintained that bleeding augments the proportion of fibrine and that the blood 
becomes more coagulable. Brichetau affirms that it is after the second bleeding that this 
augmentation in the proportion of fibrine is produced. 

Other authorities, as Nasse and Jiirgensen, have also noted increase of fibrine, and 
with their observations agree those of Hayem. Brucke and Magendie, Coze, Hirtz, singu- 
larly enough, have arrived at precisely opposite conclusions. 

Darsonval has found constantly in the dog after bleeding, notable proportions of pep- 
tones in the blood. These peptones come from the auto-digestion which ensues after each 
bleeding, (a) 



(a) Provost et Dumas, Examen die san£ et de son action dans les diff events phe'nomenes de la vie {Ann. 
de chimie et de phys.. t. XXIII, p. 51, 1825*. — Jiirgensen, Blutentziehungen {Hand, der, Allgem. thevapie. Bd 
I, p. 163, 1880). — Andral, Gavarret, Delafond, Reckerches sur la composition du sang de puelques animaux 
domestiques dans I 'e'tat de sante et de maladie {Ann. de chim. et de phys. s t. V. p. 304, 1842. 



ON BLOODLETTING. 215 

This same modification in the nutrition is still further indicated by the 
diminution in the quantity of gases dissolved in the blood. 1 Lothar Meyer 
Mathieu, Urbain, Vinay, and Noil, have in fact observed a decrease in the 
quantity of carbonic acid, and especially in that of oxygen. 

Bleeding has also an influence on the circulation. It at once modifies the 
pulse, and here, too, Hayem has shown us these modifications in the frequency, 
force, and form of the pulse. We must here distinguish the effect of one bleed- 
ing from that of several, and this distinction should always be made when the 
physiological effects of blood emissions are to be studied. When there has 
been but one bleeding, the pulse, half an hour afterward, becomes slowed ; 
when on the contrary there have been repeated bleedings, the pulse augments 
in frequency in a sensible manner ; in augmenting in frequency it diminishes in 
force, and its form takes on that which is observed in cases of anaemia or aortic 
insufficiency. The ancients attached great importance to this action of blood- 
letting on the pulse ; they maintained that bleeding raised the pulse. One can 
readily understand, to-day, that this increased amplitude of the pulse results 
not from the greater energy of the circulation, but from the diminution of the 
vascular tension in consequence of the loss of blood. 2 

1 Lothar Meyer, Vinay, Mathieu, and Urbain have remarked a diminution in the pro- 
portion of C0 2 , and especially of O in the blood, after bloodletting. 

Hayem, after an exhaustive study to determine the respiratory capacity of the blood, 
with relation to haemoglobin, concludes that this respiratory capacity remains appreciably 
proportional to the contained haemoglobin, (a) 

2 Hayem has remarked, after one bleeding, increase of pulsations during the operation, 
but this increase ceases half an hour afterward. When the hemorrhage is mortal, the pulsa- 
tions increase at first, then diminish, and become irregular at the moment of death. 

In the case of repeated venesections, the augmentation of pulsations becoms more and 
more marked with each bleeding, as is seen by the following table : 

Before first bleeding 122 pulsations per minute. 

During " " 164 

One half hour after first bleeding 149 " 

Immediately " " " 180 " " 

Before second bleeding, 24 hours later 148 " " 

During " " " " 204 " 

Immediately after second bleeding, 24 hours later. . . 189 
One-half hour " " " " " ....209 

Before third bleeding, three hours later 188 " 

During " " " " " 240 

Immediately after third bleeding, three hours later. .220 

One-half hour " " " " " 4> ..220 " 

As for the force, Vinay from his experiments concludes that the force dimin- 
ishes with acceleration of the pulse, and this is the rule in bleedings of moderate 
intensity. In fine, as to the form, after abundant hemorrhages the character of the pulse is 
like that observed in aortic constriction and insufficiency, (b) 

(a) L. Meyer, Die gase des blutes (Zeitscher. f. rat. Med., Bd., 8, s. 256, 1857). Mathieu and Urbain, 
Des Gas du sang, experiences physiologiques, etc. (Arch, de Phys., 1872). Vinay, Thdse agre*g., 1880. 
Hayem, Lecons sur les modifications du sang, 1882, p. 227. 

(b) Hayem, Modifications du Sang., p. 177. Vinay, Des Emissions Sanguines dans les Maladies Aignes, 
These de Concours, 1880, p. 25. 



•216 ON BLOODLETTING. 

These modifications of the pulse are subordinate to the disturbance occa- 
sioned in the blood-pressure. For it is now admitted by all experimenters — 
Volkmann, Navrotky, Gatzirck, Vorm-Muller, Vinay, Hayem — that hemorrhages 
diminish the blood-pressure; 1 but in order that this diminution may be effected 
and maintained, considerable losses of blood are required, for, as Vinay and 
Arloing have shown, these circulatory depressions disappear with great rapidity. 
This diminution in pressure is accompanied with a swifter blood-current, but on 
condition always that the hemorrhage has not been too considerable. 

These circulatory modifications give rise to troubles more or less profound 
in the functionating of the different organs. The respiratory movements, at first 
slowed, become more frequent, and more tumultuous in proportion as the hem- 
orrhage becomes more considerable. Nevertheless, when the blood loss is 
moderate in amount, the dyspnoea is diminished; and this it is that explains the 
relief experienced by most patients affected by pulmonary diseases after bleed- 
ing. These respiratory troubles are connected with the perturbations caused in 
the functions of the nervous system by bloodletting. 3 

This role of the nervous system renders more complex than one would 
suppose the question of the physiological effects of blood-letting. Since we 
have learned the existence of the vaso-motors we are obliged to assign to the 
nervous influence, modified by the hemorrhage, a part quite as important as we 
ascribe to the direct effect of the loss of blood on the mechanical and physical 
conditions of the circulation. 



1 According to Volkmann's table, the normal vascular pressure being 155, a bleeding of 
2 per cent, of the weight of the body reduces the blood-pressure to 56, and one of 3 per cent, 
to 30. Vinay and Arloing have estaDlished the following laws: 

1. That venesection produces immediately a considerable lowering of blood-pressure 
in the arteries. 

2. That equilibrium is reestablished with great rapidity. 

3. That copious bleedings effect great oscillations of pressure. 

According to Hayem, the lowering of pressure is not progressive. Scarcely appreciable 
in the first fifth of a mortal hemorrhage, it is between the first and second fifth that the dimi- 
nution takes place the most rapidly. It is inappreciable in the last stages of the hemorrhage. 

According to Vinay, small or medium- sized hemorrhages are accompanied with a more 
marked irrigation of the tissues, but when the loss becomes more considerable the course of 
the blood changes, and is slowed, (a) 

2 Lichtenstein has remarked a diminution in the number and profundity of the respira- 
tions following medium hemorrhages. Bauer has arrived at the same results, but when the 
hemorrhage is more considerable, this diminution gives place to augmentation. In the 
experiments of Hayem, the respiratory movements augment and become more and more 
irregular in proportion as the hemorrhage continues. 

These modifications result from the anaemia of the spinal cord produced by the loss of 
blood, {b) 



(«) Volkmann, Hemodynamik, 1850. Vinay, op. cit., p. 21. Hayem, op. cit., p. 162. Gatzirck, Cen- 
tralbl. f. d. Med. Wissensch, No. 53, p. 883, 1871. 

ib) Lichtenstein, Zeitschrift f. Biolo^ie, Bd. vii, a Hft. Bauer, Geschicht des Aderlasses, Munchen, 
1870. Hayem, op. cit. 



ON BLOODLETTING. 217 

We ought also to attribute to this double influence the action of bleeding 
on the temperature. 1 

Bleeding lowers the animal heat, and this in the normal as well as in the 
pathological state. It even seems to me that we have not of late years insisted 
enough on the therapeutic value of this powerful anti-thermic means. I know 
of none more active or more efficacious, and in contemplating what sometimes 
takes place in certain pyrexias, as typhoid fever, one is tempted to ask if it 
would not be well to return to the practice of bloodletting, after the manner of 
our fathers. This is what happens with our typhoid patients: when in the 
course of this disease a moderate hemorrhage appears, you see immediately the 
thermometric curve fall, and this lowering of temperature long persists. I 
know that this benefit is obtained at the expense of a convalescence often long 
and painful, but the fact none the less remains that, placing ourselves exclu- 
sively on the stand-point of hyperpyrexia, bleeding is a powerful depressant of 
this high temperature, and I am astonished to see an attentive observer like 
Lorain consider this fever-fall as transient and illusory. 

Bleeding acts not only on the circulation, on the respiration, on the nervous 
system, on the temperature; it modifies the organism in its entirety, and the 
conditions of nutrition even. 

Every abstraction of blood, as Lepine, Bauer, Claude Bernard, and especi- 
ally Hayem, have shown, energizes the nutritive movement; but this activity 
produces, if the bleedings are prolonged, a fatty transformation of the different 
organs, and particularly the heart, and this is a point which must not be lost 
sight of. 2 

If, then, I were to sum up the physiological effects of bloodletting, and 
with special reference to its pathological applications, I would say: sanguineous 
losses of medium intensity diminish the number of globules and raise the pulse, 
while they enfeeble the blood-tension; they also lower the temperature; their 

1 In animals a lowering of temperature is observed after hemorrhage. The experi- 
ments of Marshall Hall, of Boerensprung, of Gatzirck, and of Hayem, were absolutely 
demonstrative of this; in man the pathological temperature falls also. At the same time 
Thomas and Lorain have considered this fall as transient and illusory, (a) 

2 Experimentally, under the influence of bloodlettings, instead of obtaining a slowing 
of the nutritive exchanges, there is an acceleration; the experimental researches of Lepine 
prove this. According to Claude Bernard, bleeding has a constant effect to accelerate and 
provoke the organic exchanges. Bauer has studied experimentally on animals the action of 
bloodletting on nutrition, and he proves by the examination of the urine, as well as by that 
of the gases of respiration, that there is an exaggeration of the phenomena of denutrition and 
accumulation of fatty matters. He insists especially on the augmentation of urea, which is 
produced immediately after the bleeding, and which persists for several days. According to 
him, bleeding causes not simply a loss of fluid pabulum, but a real alteration of the organs 
and tissues. There is also a perturbation of nutrition under the influence of repeated bleed- 
ings, characterized especially by fatty transformation of the organs, and in particular of the 
heart, as Perl has shown, {b) 



(a) Gatzirck, Centralb., 1871, p. 53. Boerensprung, Muller's Archiy, 1851, p. 126. Hayem, op. cit. 

(b) Lepine, Soc. de Biologie, 1880. Perl. Virchow's Archiv, 1873, pp. 39-51. Bauer, Zeitschrift f. Biologie, 
viii. Bd., 4 Heft., Munich, 1872. 



218 ON BLOODLETTING. 

effects, however, are generally temporary, for the reason that they provoke a 
haematoblastic crisis, which tends to bring back the blood to the state in which 
it was before the hemorrhage, and if the latter be often repeated, the haemato- 
poietic formations exhaust the organism, and speedily produce grave disorgan- 
izations in the different viscera. 

Local bloodletting has general effects analogous to general bloodletting, 
but it has local effects quite different. The mode of performance of these local 
abstractions of blood is very variable; sometimes we open the vein directly, 
sometimes we have recourse to mechanical means, as wet cups, or we employ 
leeches. Local bleeding, properly so called, that is, the opening of certain 
veins by the lance, has fallen into greater desuetude than venesection at the 
bend of the elbow. Nevertheless, latterly, Arango, Chaparr, Mestivier, and 
especially Aran, have endeavored to revive the old practice, vaunted by Hippo- 
crates, Galen, and Alexander, of Tralles, of bleeding from the ranine veins of 
the tongue, while Seutin, Cruveilhier, and Denuce have proposed to take blood 
from the nasal mucous membrane, thus going back to another ancient practice. 
At the present day, despite these tentatives, local venesections are abandoned, 
and we have recourse only to leeches and wet cups. 1 

Cupping is to-day very much in use, in spite of our repugnance to let 
blood, and you see it employed in a considerable number of affections, and in 
particular in ocular therapeutics. 

Here, as in the case of venesection, I refer you to your manuals of minor 
surgery for the details of the operation, reminding you only that under the 
name of pneumodern, Montain, of Lyons, and under the name of terabdele, Da- 
moiseau, have devised cupping apparatus similar to those which Heurteloup 
and, more recently, de Wecker devised and used in inflammatory affections of 
the eye, and which are veritable artificial leeches. 

As for leeches, they render us daily great service, although we have much 
restricted their usage. 2 The application of these leeches, the hemorrhages 
which result, the means of augmenting the flow of blood, or of arresting it — 
these are points with which you are all familiar, and which you learned at the 
commencement of your medical studies. 

1 Cupping apparatuses are too well known to require description in this place. The 
instrument by which the air is exhausted by means of a pump is much the more advanta- 
geous. The apparatus with rubber ball, operated on the principle of the modern breast- 
pump, is much employed; at the same time only a partial vacuum is produced by it, and its 
action is less energetic than that of the pump apparatus. 

An interesting modern invention is the little scarifier, furnished with an air exhauster 
and described under the name of artificial leech. That of Heurtloup is the most used. 
These artificial blood-suckers are to-dav reserved entirely for ocular affections, (a) 

2 The leech belongs to the class Annelidae and to the order and family Hirudo. The 
species employed in medicine are especially the gray leech (Hirudo medicinalis), the green 



(«) Mestivier, on Bleeding from the Ranine Veins in Diseases of the Pharynx (Bull, de TheYap,, t. 52, p. 
12, 1857); Arango, Treatment of Quinsy by Bleeding from the Ranines (La Union, January, 1883); Chaparr 
(Gaz. hebd. de M^d., April, 1855); Aran, Bleeding from the Ranine Veins in Diseases of the Larynx and 
Pharynx (Bull, de Th^r., t. 52, p. 105); Denuce\ Bleeding Practiced from the Nasal Mucous Membrane (Journ. 
de Medicine de Bordeaux, August, 1856). 



ON BLOODLETTING. 219 

I will now show you what are the physiological and therapeutical effects of 
local bloodletting — effects which, in some respects, surpass those of general 
bleeding. 

Local bloodletting, whether by scarifications, by cupping, or by leeches, 
has a double action — a general effect and a local effect. When it results in an 
abundant loss of blood, it produces the same modifications as general blood- 
letting; the pulse rises, the blood-pressure falls, and the temperature is lowered, 
the most marked effect, however, and the one most often sought, is the local 
action, and this is determined in part by the hemorrhage, and in part by a re- 
vulsive influence .provoked by the local pain. 

As for the hemorrhage, the anaemiating action takes place not solely at the 
point where you apply the leeches or the cup, but it extends more or less far. 
Despite the affirmations to the contrary of Binz and Struthers, I persist in 
thinking with Johnson that a considerable area may be exsanguinated by the 
local bleeding, and this owing to the vascular communications which unite cer- 
tain organs to certain points of the skin; owing also to the intimate connections 
of the cutaneous nervous filaments, which hold under their dependence the 
vaso-motor innervation of organs situated more deeply. 

The role of the local pain determined by the punctures is as important as 
that of the hemorrhage. We have here, first of all, a substitutive effect, then a 
vaso-motor action. We know, in fact, and on this point I insisted when con- 
sidering the revulsive method in its application to the treatment of diseases of 
the spinal cord, that revulsion produced in any point of the skin causes an- 
aemia of organs more or less deeply situated. Hence it is that local bloodletting 
has remained one of our most powerful therapeutic agents to combat the ele- 
ment congestion and the element pain, and especially the association of these 
two elements. 

I come now to the most delicate and difficult part of my subject — namely, 
the indications for bloodletting, general and local. We will begin with the 
first. 

leech (H. officinalis); this kind is greener than the preceding, and the belly is not spotted; 
the dragon leech (H. trochina), which has on its back six rows of reddish or black points. 

Moquin Tandon estimates that one officinal leech of small size will draw twice its 
weight of blood. This estimate is less that the reality, for an average leech will take almost 
an ounce. 

To encourage the leeches to take hold it has been advised to wipe them with a linen 
cloth before applying them, or to dip them in wine. 

Various processes have been recommended to stanch the bleeding produced by leeches. 
One of the best consists in closing the puncture with a serre-fine. 

Statistics (which it is not necessary to produce here) show that there has been a stead- 
ily decreasing employ of leeches in the hospitals of Paris from 1820 to 1875, inc. 

Thus, from an annual expenditure in 1820, of ten thousand francs a year, for the single 
item of leeches in the hospitals; in 1875 the amount expended was only eighteen hundred 
francs; a remarkable diminution. It is also worthy of the remark a propos of these figures, 
that the number of patients attended in the hospitals is to-day double, if not almost triple 
what it was in 1820. (a) 



(a) Lasegue et Regnault, La TheYapeutique jugee par les chiffres (Arch. gen. de me"d., 6th Sene, t. 29, p. 21) 



220 ON BLOODLETTING. 

If you reconsider the physiological effects of bloodletting, you observe 
that these effects are very transient, and cannot be persistent, except on con- 
dition either that your bleeding be exceedingly abundant, or frequently repeated, 
coup sur coup, after Bouillaud's fashion and that of the ancient phlebotomists. 
While, therefore, these repeated venesections undoubtedly do produce durable 
results, it is necessary to keep in mind that, despite the haematoblastic crises 
which they determine, they are followed by a persistent anaemia, and, what is 
especially worthy of being remembered, by a tendency to fatty degeneration of 
different viscera; and one may well ask if the inconveniences and the dangers 
which result from this double pathological state do not far more than counter- 
balance the feeble benefits which are obtained from these abstractions of blood, 
so that to-day, all these facts being well weighed, everybody is agreed to solicit 
from phlebotomy only the transient effects which it can produce, and to resort 
to it only for relief of active and passive congestions of different organs. 

There is especially one pathological condition where this depletion — tem- 
porary as it may be — of the circulatory system, by bleeding, may render us 
some service. It is when we have to do with those pulmonary congestions 
which are accompanied with asystolia, and especially those which are not 
linked to fatty degeneration of the heart. You understand how, in these 
asphyxiating periods of cardiac affections, a temporary depletion is sufficient to 
enable the heart to recover its habitual rhythm. 

In the phlegmasia^, properly so called, after the congestive period has gone 
by, and the exudation has formed, bloodletting can have little or no influence, 
as I explained to you when on the treatment of inflammation of the lungs. 

Impotent to arrest the march of an inflammation, bleeding may nevertheless 
act the part of a prophylactic in these phlegmasia^; and if experimentation in 
animals does not sufficiently explain these facts, clinical experience, and 
especially clinical surgery, shows us again and again the happy influence of 
general bloodletting in averting the inflammatory accidents which traumatisms 
determine. Hence it is that bloodletting, seldom employed in clinical medi- 
cine, is still utilized in clinical surgery. 

In the treatment of the essential fevers, bleeding can have only an antipyretic 
effect, and I shall have more to say of this when I come to fevers. This anti- 
thermic action is purchased at the cost of a profound trouble inflicted on the 
economy; nor, for all that, is the course of the febrile phenomena affected 
thereby. The doctrine of microbes which, in our day, plays so important a part 
in the pathogeny of the infectious diseases, explains for us sufficiently the 
impotence of bloodletting in these pyrexiae, since the removal of blood can in 
no way prevent the development of these micro-organisms in the mass of the 
circulating fluid. 

Bleeding is indicated much more in the inflammatory fevers, or, at least, in 
those which accompany local inflammation — fevers which present often a great 
elevation of temperature, as pneumonia. When we refer to the physiological 
effects of bloodletting, it is easy to understand the ancient popularity and 
universality of this therapeutic measure, since, directed to an affection which, 
by its normal evolution, tends toward recovery, it relieves the oppression of the 



ON BLOODLETTING. 221 

patient, lowers the temperature, and gives a marked elevation to the pulse. 
But our predecessors were ignorant of the price which they paid for this passing 
amelioration. 

Nevertheless, in certain cases of blood-poisoning, obscure in their nature, 
bleeding has a happy influence. Thus in the eclampsia of puerperal women 
general bloodletting, practiced heroically, has arrested the convulsions, and all 
authorities seem unanimous in recommending venesection in these cases, 
although we are unable to explain the curative action of this spoliative treat- 
ment. 1 You see then, gentlemen, that general bloodletting is indicated only 
in eclampsia and in certain congestive states, especially such as arise from 
temporary perturbations of the cardio-pulmonary circulation, and that even here 
the relief obtained from the depletion is only momentary. 

Local bloodletting, by its double action in producing revulsion and oppos- 
ing congestion, has applications to therapeutics which are much more numerous, 
and it is a very common practice to resort to this method in painful congestive 
affections. Thus in the pain which accompanies pneumonia and pleurisy, cups 
and leeches may give relief; in congestions of the spinal cord, of the kidneys, 
of the liver, and of the uterus local depletions often prove useful. As in blood- 
letting the revulsive effects are more powerfully remedial than those resulting 
from the loss of blood, you understand the superiority of wet cups over leeches, 
and they are therefore more in use. 

Such are the considerations which I wished to present relative to blood- 
letting, and which show the mediocre but useful role which this therapeutic 
means is destined in the future to fulfill. They will, moreover, help to convince 

1 Baudelocque affirms that nothing can take the place of bloodletting in puerperal 
convulsions. Mme. Lachapelle is of the same opinion. 

Depaul has carried out the practice of blood-letting to great lengths in puerperal 
cases. He is in the habit of letting blood to the amount even of 2,000 grammes. The 
results of his practice are seen in the following table by Charpentier: 

AT THE MATERNITY. 

Single bleeding, 36 per cent, deaths. 
Repeated " 33 " " 

OTHER OBSERVATIONS. 

Single bleeding, 30.6 per cent, deaths. 
Repeated " 21.6 " " 

We may conclude from these figures that repeated bleedings have given better results 
than single bleedings. 

Peter has resumed this investigation and concludes in favor of bloodletting, not only 
as a curative, but also as a preventive measure. It has even been recommended to employ 
bloodletting in all cases of uraemic convulsions, and Fonnsagrives and Peter have cited cases 
of speedy recovery under the use of these bleedings, (a) 



(a) Lachapelle (Mme.), Pratique des accouchements, t. in, p. 29 et 30. — Depaul, Bull, de e'Acad. de 
Medic, 1854. — Charpentier, De l'influence des divers traitements sur les acces eclamptiques, these d'agr^gation, 
1872.— Peter, Lecons de Clin. Me\L, t. n.— Fonnsagrives, Considerations pratiques sur Taction d^pl^tive des 
emissions sanguines generales (Bull, de the>., t. n, p. 5, 1859). 



222 ON BLOODLETTING. 



you that, notwithstanding the opposition which we have been called to witness 
against bleeding in all its forms, and the decadence into which it has fallen, it 
ought not to be completely abandoned. 

In the next lecture I shall treat of one of the consequences of blood- 
letting; I refer to anaemia and its treatment. 






ON THE TREATMENT OF ANEMIA. 

Summary: — History — Anaemia and Chlorosis — Different Kinds of Anaemia — Alteration of the 
Blood in Anaemia — Red Blood-Corpuscles, Their Composition — Oxy-Haemoglobin — 
Evolution of the Globules — Essential and Symptomatic Anaemia — Chlorosis — The Im- 
portance of Enumeration of the Globules, and Dosage of the Haemoglobin — Treatment 
of the Anaemias — Pharmaceutical Treatment — Iron — History — The Action of Iron — Ab- 
sorption of Iron — Elimination of Iron — Mode of Introduction of Iron — Ferruginous 
Preparations — Reduced Iron — Oxides of Iron — Dialyzed Iron — Ferrous and Ferric 
Salts — Ferruginous Preparations in General — Ferruginous Waters — Artificial Ferrugin- 
ous Waters— Choice of Ferruginous Preparations — Inconveniences of Iron Medication — 
Constipation — Blackening of the Teeth — Gastric Pains — Quantities of Iron Absorbed 
per Day — The Specific Action of Iron — Adjuvant Medications — Manganese — Arsenic — 
Hydrotherapy — vErotherapy — Hygienic Treatment — Alimentation — Must We Treat All 
Cases of Chlorosis? — Pernicious Anaemia, Its Treatment. 

Gentlemen: There are no diseases more common than the various forms 
of anaemia, and this age of ours is especially the age of anaemic patients. The 
treatment of anaemia is, therefore, worthy of your serious, earnest study. 

Ever since Varandal, professor of the faculty of Montpellier, in 1620, in- 
troduced the term chlorosis into pathology, and Daumius, a century later, wrote 
the word anaemia, these two affections have been the subject of long discus- 
sions, some authorities making them two distinct diseases, others including 
them in the same description, and successive attempts have been made to 
found these opposing views on arguments drawn from clinical medicine and on 
arguments drawn from the chemical examination of the blood. 1 

1 If the ancients understood anaemia, they have said little about it in their writings. 
In Hippocrates indeed the word anaima is found, and is applied to persons in a miserable 
exsanguinated condition. Galen makes no mention of anaemia. 

In 1620 Varandal in his treatise on Diseases of Women, made mention of the pale 
color of certain patients, and proposed for this condition the word chlorosis. In 1706 Euth 
proposed the name oligaemia to characterize the lack of blood. In 1732 for the first time we 
find the word ancemia in the inaugural thesis of Daumius, Mich. Alberti being dean of the 
faculty. Then a few years later appeared the theses of Kutter and Behr on anaemia. Not- 
withstanding these works, anaemia was exceptionally admitted in France. Bouillaud in 1833 
pointed out the anaemic souffles of the heart and blood vessels. Piorry called attention to 
local and general anaemias ; finally the labors of modern haematology enabled *us better to 
understand anaemia. 

Then came the numerous divisions corresponding to the varieties of anaemia which were 
being studied, and an attempt was made to establish between anaemia and chlorosis distinc- 
tions more or less precise, and based more particularly on the alterations of the serum 
and the alterations of the globules. Thus Germain See admits four types of chronic 
anaemia : oligaemia corresponding to a diminution in the whole mass of the blood ; globular 
anaemia ; hydraemia, characterized by augmentation of the watery principles of the serum ; 
disalbuminaemia in which there is diminution in the proportion of albumen. Moreover he 
establishes a distinction between chlorosis and anaemia. He regards chlorosis as a globular 
anaemia, resulting from nutritive impoverishment entailed by the demands of the reproduc- 
tive functions and of growth. Jaccoud thus distinguishes anaemia from chlorosis : In 

223 



224 ON THE TREATMENT OF ANvEMlA. 

The incessant progress which the physical sciences and chemistry have 
made in the study of the blood, enables us at the present day to know the 
veritable nature of the anaemias. At first characterized and described as a 
diminution in the whole mass of the blood, the anaemias were subsequently con- 
sidered as resulting from modifications in the divers constituent elements of 
that fluid. Hence in correspondence with the ingredient lacking, or in excess, 
different varieties of anaemia were established ; essential globular anaemia, hy- 
draemic anaemia, polyaemic anaemia (poly-anaemia) according as the globules 
alone were diminished in number or as there was predominance of the serous 
elements or even diminution in the proportion of albumen, such deficiency 
being indicated by the word disalbuminaemia, coined by Germain See. 

To-day these distinctions ought to be abandoned, not because, irrespec- 
tive of globular deficiency, these alterations in the constituent elements of the 
blood do not exist, but because they are variable and are not based on any very 
positive mathematical data. On the other hand, by reason of the discovery of 
processes which enable us not only to number the globules, 2 but to judge of 

chlorosis the blood alteration is purely globular ; it is an essential globular anaemia. In 
anaemia proper there is modification of the other constituent elements of the blood. 

Under the head of anaemia we distinguish : 

i. True or post haemorrhagic anaemia. 

2. Serous or polyaemic anaemia. 

3. Albuminous or hydraemic anaemia. 

4. Globular anaemia, or chlorosis. 

Hayem has shown that in chlorosis the trouble is with the evolution and complete 
development of the red globules.' (a) 

2 The discovery of the blood globules was one of the first triumphs of the microscope. 
It was in 1661 that Malphigi perceived in the blood of a hedge-hog certain red and spherical 
corpuscles which he considered to be globules of fat. Swamnerdam had, however, several 
years before, namely in 1658, made the discovery of these globules in the blood of a frog, 
but these investigations had not been published. In 1673, Leuwenhoek showed that the 
blood globules exist in the blood of all animals and that it is to them that the red color is 
due. Finally in 1770 Hewson completed this discovery and studied the structure of these 
bodies, their form, their dimensions, and published a very important work on the solid par- 
ticles of the blood. 

To-day we know the precise constitution of these corpuscles. In man the globules 
have the form of circular discs flattened in the centre. They are oval and elliptic in birds, 
fishes and reptiles. 

Their dimensions vary according to the species and conform to the two great laws laid 
down by Milne Edwards : 1. Throughout the entire animal scale, in proportion as the organ- 
ism progresses towards perfection of type, the globules decrease in size. 2. In animals 
belonging to the same zoological group, the more active the respiration the smaller the glob- 
ules. 

In man these dimensions according to Hayem vary from 5ms to 8 m 6 (m = i-tooo 
millimetre). 






(a) Varandceus. De Morbis Mulierum, 1620, Lib. 1, ch. 1. Daumius, Diss. Inaug. Med. de Ansemia, 
1732. Kutter and Behr, Opera, 1766. Bouillaud, Jour, hebd., 1833, t. ix., p. 578. Piorry, Trails des Altera- 
tions du Sang., Paris, 1836, p. 21. G. See, Lemons de Path. Experiment, Paris, 1867, pp. 38 and 244. Jaccoud, 
Path. Int., 1871, t. ii., p. 819. Hayem, On the Anatomical Characteristics of the Blood in the Anaemias, 
Compt. Rend, de l'Acad. des Sc, July, 1876. Moriez, De la Chlorose (th. d. agrdgation, 1880). 



ON THE TREATMENT OF ANAEMIA. 225 

their quality, we can by this very examination of the globules find a basis for 
the entire study of the anaemias. Here, moreover, it is to Professor Hayem 
that we are under obligations for the most important and decisive investigations 
on the characters of the blood in anaemic persons. 1 

Constituted by a solid organic frame-work provided even, if we may accept 
the latest researches of Ranvier, with a spherical membrane, the red corpuscles 
circulate in large numbers in the blood current. Deprived of nuclei, at least, 
as a rule, except in the foetus, having a distinct form with which you are all 
familiar, these red corpuscles have a chemical composition to-day well known. 
They are constituted by an albuminoid matter, globuline, and contain also 
lecithine, cholesterine and animal matters, but that which especially character- 
izes them is the presence of a complex azotized matter colored red, crystalliz- 
able, containing a notable proportion of iron, the oxyhemoglobin. 

This oxyhemoglobin is the veritable factor of the respiratory power of the 
blood; it presents to spectral examination certain characteristic rays which I 
here show you in this drawing, and when it is deprived of its oxygen, it con- 
stitutes what is called haemoglobin reduced, which offers (and this is an import- 
ant point) a spectral appearance quite different, as you can judge on comparing 
the two figures which I place before you. Apart from this reduced haemo- 
globin, oxyhaemoglobin gives rise to other products of decomposition, such as 
haematin, haemochromogen, haemin, and haematodin. 

You know from what I told you in a previous lecture, the methods in vogue 
for ascertaining approximately the amount of haemoglobin in a given quantity 
of blood. 

Anaemia of every kind, resulting as it must from an affection localized in 
the red globules, it is absolutely necessary that you chould have precise knowl- 
edge of the constitution of these globules and their evolution. Having finished 
the first part of my task, I come to the second, which concerns the evolution of 
the blood-corpuscles. 

Here, unfortunately, our data are less conclusive, and we are obliged to re- 
sort to conjectures. 2 At the same time we know, according to Professor 

1 The number of these globules in the blood is estimated by Hayem as 5,000,000 per 
cubic millimetre. Their structure has been the subject of numerous researches, the most im- 
portant of which are those of Rollet and Ranvier. Rollet maintains that the corpuscles are 
deprived of envelop, and are constructed of a solid organic frame-work, soft and uncolored, 
which he calls stroma, and which imbibes haemoglobin like a sponge. Ranvier insists that 
there is a membrane around them. Sappey affirms the existence of a nucleus in the human 
blood globule. Hayem has found this to exist exceptionally, and in particular in cases of 
leucocythaemia. To detect these nuclei you must have a special staining fluid, either iodo- 
ioduretted water or hematoxylin, (a) 

2 It has till quite lately been supposed that the red globules come from the lymph and 
chyle, and that it is in the blood itself that the transformation from lymph globules into 
blood globules is effected. Within a few years, the tendency has been to assign to certain 
organs the function of transformation of the leucocytes into red globules. The red corpus- 



(«) Rollet, Sitzunsber der Wiener, Akad. der Wissensch., t. xlvi, May, 1862. Ranvier, Researches on the 
Elements of the Blood, Arch, de Physiol., 1874, p. 790. Hayem, Nucleated Red Globules in the Blood of the 
Adult, Arch, de Phys., t. i., March 1st, 1883. 
§15 



226 ON THE TREATMENT OF ANAEMIA. 

Hayem, that the red corpuscles come from those little brilliant bodies which 
you see in microscopical preparations of blood, and to which the name of 
haematoblasts has been given. But what is the source of these haematoblasts? 
Do they come, as Hayem thinks, from the lymphatic net-work ? Or from the 
marrow of bones, as the German and Italian schools maintain? Or are they 
engendered in the interior of certain glands, as the liver and the spleen? We 
are quite ignorant, and while recognizing the fact that there must be haemato- 
poietic centres, we cannot at present definitely localize them. It is probable 
that the entire economy participates in the formation of haematoblasts. 

The want of precise data concerning the origin of the blood globules, is a 
misfortune as far as therapeutics is concerned. In fact, the production of these 
haematoblasts is at the core of this whole question of the etiological treatment 
of anaemias, and if we could know the exact point where the hasmatoblasts orig- 
inate, it is to this point that all our therapeutic endeavors should be directed. 

What we do know is that under the influence of bad conditions of alimenta- 
tion, or by reason of deprivation of a plentiful supply of oxygen in the air of 
respiration, or even as a result of the absence of sunlight, the production of 

cles issue fully formed from these organs, and among these haemato-poietic organs appear in 
the first rank, the liver and the spleen. The labors of Neumann, Bizzozero, and Rindfleisch, 
have added the marrow of bones. Bizzozero's conclusions are as follows: 

1. The marrow of bones serves for the formation of white globules and lymphatic ele- 
ments. 

2. It is an organ of destruction of the red globules. 

3. It is an organ productive of the red globules in the ratio of the transformations 
which the white globules undergo in its interior. 

These views are based on patho-anatomical data and on experimental facts. After 
abundant hemorrhages in animals the medulla of bones contains a large number of nucleated 
red globules. Litten and Orth even found in the blood of anaemiated dogs nucleated 
globules. 

In pernicious anaemia the marrow of the bones has been found red and altered. 

The spleen has long been regarded as a hematopoietic organ. Bizzozero, Salvioli, 
and Foa affirm that in animals, during the first period of their life it is the spleen and the 
liver which form the globules. 

According to Neumann and Bizzozero, the successive stages in the evolution of the 
red globules are as follows: The first stage is represented by the white globules and the 
uncolored cells of the marrow. In the second stage appear the nucleated haemotoblasts. 
In the third the nucleus disappears, and the red globule is fully formed. Rindfleisch adds that 
it is the expulsion of the nucleus that gives to the red corpuscle its bi-concavity. 

Hayem, who has reproduced the greater part of these experiments, does not share 
these views of the German and Italian authorities, and while admitting that in the fcetus the 
nucleated corpuscles may have multiple origins, he believes that the red globules always 
come from the hasmatoblasts. (a) 



(a) Neumann, Ueber die beudeutung des knochenmarkes fur die blutbildung {Arch. d. heilk., Bd X, 
s. 68-102, 1869). — Neue beitrdge zur kenntniss der blutbildung {Arch. d. heilk., 1874, s - 44 1 )- — Knochenmark 
und blutkorperchen {Arch./, mikr. anat., Bd XII, s. 793). — Litten et Orth, Ueber veranderungen des markes 
in rohrenknochen unter verschiedenen patholog schen vehralenissen {Berl. kl n. Woch., s. 743, 1877). — Bizzozero, 
Sulla funzione amatopoetica del midollo della ossa {Gaz. hebd. Lombard a, n° 46, 1868). — Centralbl.f. med. 
Wiss., s. 885, 1868, n. s. 149, 1869). — Sul. midollo della ossa, Napoli; 1869. — Rindfleisch, Ueber knochenmark 
und blutbildung {Arch. /. mikr. anat., Bd XVII, s. 1, n. s.y. 21). — Bizzozero et Salvioli, Blukorperthen in der 
milz {Centralbl. die med. Wissens., s. 273,1879). — Foa et Salvioli, Suit 1 origine dei globulirossi delisangus 
{Arch, per le sc. mediche, vol. IV, n° 1. 



ON THE TREATMENT OF ANiEMIA. 227 

blood corpuscles diminishes, and the corpuscles, touched in their vitality, do 
not attain their complete development. 1 In other circumstances the original 
cause escapes us, and we see develop at certain periods of life those essential 
anaemias described under the name of chlorosis, and in which the haematopoi- 
etic centres seem primitively to have undergone some lesion. Oftener these 
troubles in the evolution of globules are temporary, but there are others which 
are permanent; we give the name malignant or pernicious to these anaemias, 
and all our therapeutic efforts are impotent in these cases to communicate a 
new activity to the production of haematoblasts. 

Whether we are concerned with symptomatic anaemia, with essential 
anaemia, or pernicious anaemia, it is always in the evolution of the corpuscles 
that we must place the first cause of the trouble, and to serve as a basis for our 
diagnosis of anaemia, and to measure the intensity of the evil, we ought always 
to refer ourselves to the three following particulars, as Hayem has shown: — 
What alterations have the globules undergone ? What is their real number ? 
what is their individual value ? 2 

1 Hayem affirms that in all kinds of anaemia you will find abnormal forms of globules, 
and in particular, giant corpuscles with a diameter of 12' m. There are other globules which 
are very minute. With these alterations in size there are alterations in shape, due to the 
abnormal softness of the globules in chlorotic patients; it is, however, worthy of note that 
the corpuscles never lose their disk shape. 

Moriez considers the theories which have been advanced respecting chlorosis under 
five heads: 

1. Chlorosis due to disturbances of menstruation. 

2. Chlorosis due to dyscrasia. 

3. Chlorosis due to disease of the nervous system. 

4. Chlorosis due to inflammatory or organic disease. 

5. Chlorosis due to faulty evolution. 

1. Chlorosis is due to menstrual disorders. — This is the view sustained by the ancient 
fathers of medicine, and multitudes of modern authorities, who have attributed to uterine 
troubles the first cause of chlorosis. 

2. Chlorosis is a cachexia, a dyscrasia. — This is the opinion the most generally adopted, 
and a great number of hypotheses have been advanced with regard to it. Some see in 
chlorosis nothing but alterations in the red globules, others alterations in the plasma as 
well. 

3. Chlorosis is a disease of the nervous system. — Sydenham compared chlorosis to hys- 
teria, regarding them as akin. Trousseau placed the disorders of the nervous system in the 
first rank, and before the anaemic troubles. Copland attributes chlorosis to asthenia of the 
great sympathetic. Hoefer, Cocchi and Braxton Hicks attribute it to neurosis of the gangli- 
onic nervous system; Putegnat to a neurosis of the trisplanchnic nerve. 

4. Chlorosis is an inflammatory or organic disease. — Broussais considered chlorosis as a 
visceral irritation. Rasori, Giacomini, and Tommasini invoke a slow arteritis, while Hoff- 
mann, Beau, and Suton place in alteration or functional troubles of the digestive tube, the 
point of origin of chlorosis. 

5. Chlorosis is a disease of evolution. — This is the opinion sustained by Germain See. 
According to him, whenever there is disproportion between the developmental forces and the 
reparatory forces, chlorosis may arise. 

2 Hayem has studied the anaemias from the standpoint of numeration of the globules, 
and of colorimetry. According to him, the elements of appreciation of the degrees of 
anaemia are in order of importance: 



228 ON THE TREATMENT OF ANAEMIA. 

This examination will be very easy for you if you follow the rules which I 
gave you in a previous lecture, and all that you have need of in order to carry 
them out, is a drop of your patient's blood. You will see then by the micro- 
scopic examination of the preparation, the form of the corpuscles, their number, 
and that of the haematoblasts; you will appreciate by this examination, which 
should be a very thorough one, how important it is to combine the numerical 
examination of the globules with the qualitative estimation of the haemoglobin, 
and always to compare the corpuscles under inspection with healthy corpus- 
cles, that you may know their real value. 

There exist, in fact, anaemias in which the number of globules is not dimin- 
ished, and this shows that the word globular anaemia, taken in its most rigorous 
acceptation, is not always an appropriate word to designate impoverishment of 
the blood. But if by means of the haemacytometer you are able to compare 
these globules with healthy globules, you will find a marked difference in their 
number. 3 We have now in our hospital wards anaemic individuals (advanced 
cases), who, by the simple enumeration of the globules, have from four to five 
millions, a figure almost normal, but which amounts to only two or three mil- 
lions when the comparison is made with well-developed healthy globules. So 
that it is not enough to have a normal quantity, they must be healthy as well. 

i. The richness of the blood in hemo-globin, expressed in the number of healthy 
globules. 

2. The alteration of the globules. 

3. The real number of the globules. 

4. The individual value of the globules. 

Basing himself on these characters, he establishes four degrees of anaemia: 

1. The mild degree of globular deficiency, characterized by alterations nil or feeble, 
by a globular richness expressed in healthy globules varying between three and four 
millions. Corpuscular value varying from 1 to 0.70. 

2. Globular deficiency of medium intensity, characterized by pronounced globular 
alterations with diminutions in the dimension of the globules; a richness varying from two 
to three millions. Individual corpuscular value varying between 0.30 and 0.80. 

3. Intense globular deficiency; having also for characteristics altered globules, but of 
very unequal dimensions, of which the medium approaches the normal by reason of the 
great proportion of giant globules; a globular richness varying from two million to eight 
hundred thousand. Individual corpuscular value oscillating between 0.40 and 1. 

4. Extreme globular deficiency, characterized by altered globules of very unequal 
dimensions, but whose medium approaches the normal, and may even exceed it; a richness 
varying from 800,000 to 450,000. An individual corpuscular value approaching the normal. 

3 According to the researches of Quinquaud, researches based on the dosage of haemo- 
globin by the process of Schutzenburger, in the blood of chlorotics there is a double altera- 
tion: diminution in the figure of haemoglobin, and lowering of the maximum of saturation 
of the blood by oxygen. The haemoglobin is diminished ]/ 2 in chloroses of medium intensity. 
In the normal state in 1000 grammes of blood the haemoglobin is 125 grammes; it falls to 70 
and even 30 grammes in chlorotics. As for the absorbent power of the blood for oxygen, it 
is normally in the ratio of 240 cu. centimetres to every 1000 grammes of blood; it falls to 80 
cu. centimeters in chlorotics. Quinquaud has also found a diminution in the salts of potash 
and chlorides which enter into the composition of the blood, (a) 



(a) Quinquaud — Researches on Clinical Haemotology, Paris. 



ON THE TREATMENT OF AN/EMIA. 229 

This microscopical examination will give you a good basis for prognosis. 
Whenever you see the haematoblasts in sufficient abundance, be persuaded that 
by reason of the conservation of the haematopoietic functions, you will be ena- 
bled easily to cure your patient. If there be paucity of haematoblasts, you will 
have difficulty in bringing about restoration, and the difficulty will be insuper- 
able if the haematoblasts be very few. 

You will pardon these somewhat lengthy details on account of the import- 
ance of such investigations as these, investigations which, though as yet little 
known and employed, have completely modified the study of anaemia. I come 
now to the practical question before us, the treatment of the various forms 
of anaemia. The treatment of anaemia is, first, pharmaceutical; second, 
hygienic. 

i. In the first rank of therapeutic agents we place iron, and this question 
of ferruginous preparations in the treatment of anaemia is one of the most in- 
teresting in therapeutics, and one which has awakened the most ardent 
discussions. 

The first physicians who employed iron in anaemia were probably guided 
by the therapeutic rule called the law of similitudes, and selecting iron as the 
representative of force — placed, as it had been, under the patronage of Mars — 
they judged this metal to be indicated in diseases characterized by great de- 
pression of the vital forces. 

In the middle of the seventeenth century Ferrein thus characterized the 
therapeutic properties of the ferruginous preparations: i. Sunt temperantes; 
2, Diluentes; 3, Solvunt et aperiunt; 4, Vi stomatica donantur; 5, Vi cathartica; 
6, Vi astringente; 7, Diureticae sunt. 

These multiple properties were based only on observation, but an im- 
portant discovery which had just been made at Bologna and at Venice by 
Galatti, by Menghini and by Badia, gave a much more powerful support to this 
ferruginous medication, since these physicians had just recognized the existence 
of iron in the blood; 1 then more precise investigations proved the presence of 
iron in the red corpuscles, and in the oxy-haemoglobin, which constitutes the 



1 The following, according to Pelouze, are the quantities of iron contained in 100 
parts of blood of different kinds: 

MAXIMUM. MINIMUM. 

Man og.0537, og.0506. 

Ox o . 0540. o . 0480. 

Hog o .0595. o .0506. 

Goose o .0358. o .0347. 

Chicken o .0357. " 

Frog o .0425. " 

Boussingault has given the following figures: 

100 grammes of human blood contain of iron ogr.051. 

100 grammes of beef's blood contain ogr.048. 



230 ON THE TREATMENT OF ANAEMIA. 

most important part of these globules. 1 As a result of this discovery iron came 
into such general use in anaemia that not a mother of family but of her own 
accord gave ferruginous preparations to her daughters when the appearance of 
pallor in the countenance indicated this medication — a custom which has pre- 
vailed to the present time. 

At the same time, despite the popularity of the ferruginous medication, 
despite the constant multiplication of new preparations of iron, this question of 
efficacy, and especially of the action of chalybeates, is far from being solved, 
and there are two ways of regarding the subject. Certain physiologists, 
emphasizing the fact of the presence of iron in the haemoglobin, and deriving 
support from the labors of Prof. Hayem, insist that a course of iron prepara- 
tions is essential to the cure of globular anaemia. Clinicians, on the other hand, 
reply that while fully recognizing the utility in certain cases of martial 
remedies, the latter, nevertheless, have no direct local action on the globules, 
and what action they have results from stimulation of the entire organism ; 
that all hygienic and other means which improve nutrition and arouse the 
haematopoietic forces, arrive at the same result. In support of this view clini- 
cians appeal to the numerous facts of chlorotic patients where martial prepara- 
tions, continued for several years, have produced no effect, and where cure has 
at last been brought about by hydrotherapy, gymnastics, and especially by 
country air. 

Till recently I have ranged myself on the side of the clinicians, but I 
acknowledge that since I have employed in the study of therapeutic results ob- 
tained, the scientific method of the enumeration of the globules, my opinion 
has been shaken, and within certain limits, which I shall fix presently, I am 
ready to endorse the claims of the partisans of the ferruginous medication. 

What renders obscure this mode of operation of chalybeates is that we are 
still ignorant of the pharmaco-dynamic action of this remedy daily employed, 



1 Haemoglobin is the most important part of the chemical composition of blood 
globules. According to Wurtz, it ought not to be reckoned among the albuminoid matters. 
It is constituted essentially by a crystallizable matter to which has been given the name of 
oxy-haemoglobin. The form of these crystals varies according to the blood from which they 
are derived, whether venous or arterial and according to the animal species from which it is 
obtained. Submitted to spectrum analysis, it presents two absorption bands situated 
between the rays D and E of the solar spectrum and separated by a luminous ray colored 
greenish-yellow. 

When you put oxy-haemoglobin in contact with a body that has a great affinity for 
oxygen, you obtain haemoglobin reduced, which is distinguished from the former in that it is 
no longer crystallizable and that instead of presenting two absorption bands it has but 
one, and this in the place of the greenish-yellow band which separates the two absorption 
bands of the spectrum of oxy-haemoglobin. 

In the presence of acids and of alkalies, haemoglobin breaks up into albuminoid coagu- 
lable substance, and an iron pigment, hematosin (which Lacanut described under that 
name); this hematosin is capable of combining with sulphuric acid and giving rise to a new 
body to which has been given the name of hematoporphyrine. It combines also with 
hydrochloric acid and forms chlorhydrate of hematine, (Wurtz, Treatise on Biological 
Chemistry, p. 297). 



ON THE TREATMENT OF ANAEMIA. 231 

and that on many points relative to the absorption and elimination of this medi- 
cament, we are reduced to hypotheses. 

As for absorption, the hypothesis of Scherpf is the most probable, who 
affirms that ferruginous preparations enter the blood under the form of a double 
salt. 1 First they may be taken up by the stomach as a chloride, which on 
entering the serum is changed to an insoluble albuminate, which is then 
rendered soluble by an excess of soda, constituting a double albuminate of iron 
and of soda. Or on the other hand this transformation into a soluble albumin- 
ate or peptonate may be effected in the intestine under the influence of the 
digestive fluids, and in this state it may be absorbed. But what has given 
place to the most controversy is the question relative to the elimination 
of iron. 2 

In fact. the whole of the iron ingested seems to appear in the faecal matters, 
and this has led the opponents of the ferruginous medication to affirm that iron 
does not undergo any change in the economy. 3 

At the same time, when we examine the question a little more carefully, 
we perceive that the iron which is found in the dejections comes not only from 
the iron introduced directly by the stomach, but also from the different in- 
testinal secretions, the gastric juice, and especially from the bile, which con- 

1 To explain the absorption of iron, three hypotheses have been admitted: I. Direct 
penetration of the iron into the blood under the form of an inorganic salt and combina- 
tion of this salt with the albuminoids of the blood. 

2. Combination of the iron and the albuminoids directly in the stomach and intestine. 

3. Absorption by these two processes at once. 

It is this last theory which has received the support of Scherpf, of Mitscherlich, of 
Buchkeim and Ditts. The theory more explicitly stated is as follows: The assimilation of 
iron is brought about in two ways — in the blood and in the intestine. In the blood, the 
iron penetrates in the state of an inorganic salt and combines with the inorganic substances 
of the serum; in the intestine there is also, before absorption, a combination of iron with 
the albuminoid matters, forming veritable ferruginous peptonates. It is probably in the 
the state of chloride that iron enters the blood. This chloride of iron, introduced into the 
blood, is transformed into albuminate of iron, at first insoluble and afterwards changed by 
the alkali of the blood into a double albuminate of iron and soda. These double albuminates 
of iron and soda and the peptonates of iron are absolutely innoxious to the blood, (a) 

2 Scherpf, On the Absorption and Elimination of Iron, Wurtzburg, 1878. 

3 Tiedmann and Gmelin found, so to speak, the whole of the iron administered to sub- 
jects under experimentation, in the stools. Most of the secretions contain iron; the 
tears, saliva, the milk, the digestive and intestinal secretion, the bile, etc. The gastric juice 
of a man, according to Schmidt, excretes three centigrams a day of iron, the bile four centi- 
grams. Paganuzzi maintained that iron absorbed in the intestines penetrated to the cells of 
the liver, there stimulated the haematopoietic functions of this gland, and was eliminated by 
the bile to be again taken up by the intestine. Hayem affirms on the contrary that the iron 
which is found in the excretions does not find its way there till it has been made a part of the 
blood globules, and that it undergoes an incessant renewal in the economy. In dogs, 
nourished on aliments deprived of iron, this metal was found in notable quantity in the 
faecal matters (b) 



(a) Scherpf, On the Resorption and Assimilation of Iron. Wurtzburg, 1878. Hayem, loc. cit. 
(5) Hayem, Lecons sur les Modifications du Sang., p. 507. 



232 ON THE TREATMENT OF ANAEMIA. 

tains iron in notable proportions. A propos of the presence of iron in the bile, 
I showed you, when addressing you on the functions of the liver, that Paganuzzi 
and Lussana had based on this fact a particular theory of the action of iron on 
the haematopoietic functions of that organ. 

It is, then, probable that the iron which is found in such abundance in 
the stools and in the intestinal secretions, comes not only from that which has 
been taken as medicine, and from the food, but also from the incessant modi- 
fications which the blood corpuscles undergo in the organism. But what is 
quite inexplicable, and altogether different from what we observe in the case of 
other medicaments, the quantity of iron found in the urine is little if at all in- 
creased, in whatever form the chalybeate may be administered, that is if we 
may rely on the experiments of Hamburger. 1 

The method of administration of ferruginous medicines is almost exclusively 
by the alimentary canal. Nevertheless the past few years attempts have been 
made to introduce soluble iron preparations hypodermically, and even by the 
rectum. Neuss has recently experimented with subcutaneous injections of the 
pyrophosphate in solution of citrate of soda. Luton and J. M. Da Costa have 
administered the dialyzed iron in the same way, the quantity for hypodermic 
injection being fifteen to twenty drops. This preparation is said to cause no local 
irritation whatever. Chiamarelli has employed to advantage the ammonio- 
citrate, one grain to about fifteen drops of water, and claims that this is a good 
and safe preparation for hypodermic use. 

Jaillet has recommended lavements of peptonate of iron, and I have myself 
practiced subcutaneous injections of the peptonates. These tentatives ought to 
be encouraged, for there are persons whose stomachs cannot support the martial 
preparations, and in these cases there will be an advantage in using the hypo- 
dermic or rectal method. At the same time it must be borne in mind that sub- 
cutaneous injections of the peptonate of iron are painful, without however being 
attended with the risk of grave local lesions. 2 

As for the preparations of iron which are administered by mouth, they 
are innumerable, and their number increases every day. They may be 
divided into the martial preparations properly so called, and the ferruginous 
waters. 

1 Hamburger has studied the elimination of iron and affirms that one will always find 
iron in the normal state in the urine, and when iron is administered to animals, for 
instance in the dose of five grammes of the sulphate per diem, this dose does not augment more 
than from one to two milligrammes the quantity of iron contained in the urine, (a) 

2 Jaillet's solution of the peptonate is as follows : Take of sublimated perchloride of 
iron, i gramme. Distilled water, 6o grammes. Dried peptone, 2 grammes. Pure glycer- 
ine, 40 grammes. Dissolve the peptone in a little water and add the glycerine; dissolve the 
ferrum perchloride in the rest of the water, and mix the two solutions, add finely pulverized 
carbonate of soda to saturation, and filter the solution; (see that the solution measures 100 
cubic centimeters before filtration). (6) 



(a) Hamburger, Ueber die aufnah me ausscheidung deseiseus. (Zeitschrift f. physiologische chemie, 
Bd. 11, p. 119,1878.) 

(i>) Jaillet, Physiological and Chemical Studies on the Chloropeptonate of Iron. 



ON THE TREATMENT OF ANAEMIA. 233 

The martial preparations are both soluble and insoluble, simple or com- 
pound. I cannot enumerate all. I will only mention the principal. Iron in 
substance has been used, the oxides and the sesqui-oxides, the ferrous as well 
as the ferric salts. 

Iron in fine powder, iron filings, porphyrized or not, and the ferrum 
redactum (or iron reduced by hydrogen or by electricity), represent the type of 
the insoluble preparations. Introduced into therapeutics by Quevenne, who 
recognized its ready solution in the gastric juice, this reduced iron has had and 
still has a great repute. [It was a favorite preparation with the late Dr. C. D. 
Meigs, of Philadelphia. — Trans.] Iron filings are also given in the form of 
powder, pills, dragees, or as iron chocolate. 

Under the name of ethiops martial, and under that of aperient saffron of 
Mars, therapeutics utilizes the dark ferric oxide, and the hydrated sesqui- 
oxide, which serves as the basis of numerous complex preparations. Of these 
oxides there is one which enjoys great repute, at least on the advertising 
pages of medical journals; I allude to the dialyzed iron, which is a very unreli- 
able preparation, if we may trust the conclusive experience of Bouchardt. 1 

Then comes the long series of ferrous and ferric salts. At their head we 
have the ferrous carbonate (the old proto-carbonate), two preparations of 
which, quite complex, are well known — Vallet's and Blaud's pills. Quite 
recently, too, under the name of the sucro-carbonate of iron, Tanret has put in 
the market a preparation very agreeable to the taste, which is a combination of 
ferrous carbonate with sugar. 2 

Next in order is the iodide of iron, which serves as basis of the pills of 

1 The following useful formulas are worthy of mention in this connection: 

Iron Chocolate. — Take of chocolate 50 parts, porphyrized iron filings 1 part. Mix. 25 

grammes represents 25 centigrammes of iron. 

Chalybeate Pill — (Each pill contains 1 grain porphyrized iron filings, with about l /$ 

grain socotrine aloes and pulv. canella, made into a pill with a little powdered licorice root 

and honey.) 



Compound Iron Pills. — ^ 



GRAMMES. 



f Quevenne's iron o 16 

For one pill. Sulph. quinine o 01 

J Pulv. zingib o 01 

) Ext. cinchon. fiav o 03 

Dose, from one to six. Ext. rhei co o 03 

[ Aloes soc o 005 

Mist. Fer. Aromatic. — (Dublin Ph.) 

5 Iron filings, 15 grammes (gr. ccxxv). 
Yellow calisaya bark, 30 grammes ( § i). 
Columbo root, 12 grammes ( 3 iij). 
Cloves, 8 grammes ( 3 ij). 
Peppermint water, 200 grammes ( \ vi and 3 v). 

M. Macerate three days, shake and filter, then add enough tincture orange peel to 
flavor. Dose, two to three teaspoonfuls a day. 

2 The formula of Vallet's pills is as follows: 



234 ON THE TREATMENT OF ANAEMIA. 

Blancard, the syrup of which is so much used in the treatment of scrofula; the 
potassio-tartrate, of which the celebrated balls of Nancy are composed, and 
which are called the balls of Mars; 3 then the ammonio-citrate, and the simple 
citrate; the lactate which Gelis and Conti have introduced; the pyrophosphate 
(a very elegant preparation), the chloride and the oxychloride; and, in fine, the 
recent combinations of iron and albumen, known as the albuminate and the 
peptonate of iron. One of my pupils, Dr. Chalhoub, has recorded in his gradu- 
ating thesis the principal trials which I have made with this peptonate of iron. 4 
But you are not to believe that all the preparations into which iron enters 
as a component can be utilized in therapeutics, for there are some that are not 

5 Crystallized sulphate of iron, pure, 20 grammes ( 3 v). 
Crystallized carbonate of soda, pure, 24 grammes ( 3 vi). 
Simple syrup, 9 grammes (gr. cxxxv). 
Treacle, 3 grammes (gr. xlv). 
Water (boiled and deprived of air, and sweetened), q. s. 

M. Ft. massa; divide in pil. No. 150. 

Blaud's pills are as follows: 

^ Dried sulphate of iron, 

Pure carbonate of potassa, aa 30 grammes ( § i). 

Pulv. acacias, 5 grammes (gr. lxxv). 

Water, 20 grammes ( 3 v). 

Syrup simplicis, 15 grammes ( 3 iij and gr. xlv). 

M. Divide into 120 pills. 

The formula of the Belgian Ph. is very simple. Each pill consists of the following 
ingredients: 

J3> Crystallized carbonate of soda, 
Crystallized sulphate of iron, 
Treacle, 
Myrhh, aa 5 centigrammes (or about 1 grain). 

[The sucro-carbonate of iron of Tanret, resembles the saccharated carbonate of iron 
of the British Ph.] 

3 The ferri et pot. tart, is made by the contact of pulverized cream of tartar with 
hydrated sesquioxide of iron; it is the basis of several popular combinations. The tartarized 
tincture of Mars (French Codex) is made as follows: Take of iron filings, 10 grammes; pul- 
verized cream of tartar, 25 grammes; distilled water, 300 grammes; alcohol, 5 grammes. 
Macerate a suitable time and filter. The balls of Mars are composed of iron filings, cream 
of tartar, and certain vulnerary herbs. They are made into balls weighing an ounce, very 
hard and very soluble. When used, a little is scraped off, dissolved in water, and drunk; it 
is the a called eau de boule, and is a popular chalybeate. 

4 Chalhoub, Study on the Chloro- Peptonate of Iron (These de Paris, July, 1883;. [The 
tincture of chloride of iron is probably the most used of all the preparations of steel in this 
country. It is, however, likely to affect the teeth, from the free HC1 which it contains. 
This may in a measure be obviated by mixing it with syrup, and then with milk; the styptic 
taste is then no longer apparent {Vide Druggists' Circular, June, 1881). It is worthy of note 
that Squibb regards the tinct. fer. chlorid. of the U. S. P. as a mistake. It is not fit for use 
till six months old. An imoortant part of its therapeutic value depends on the ethers which 
are slowly generated from the HC1. and the alcohol. Trans.] 



ON THE TREATMENT OF ANEMIA. 235 

susceptible of absorption when ingested. I cite especially the ferro-cyanide of 
potassium, and Regnault and Hayem have shown us by precise experiments 
that this salt traverses the organism without undergoing any change, and with- 
out producing any modification of the state of the blood-corpuscles. 

When one takes a general view of all these preparations, it is easy to see 
that their authors have yielded to two tendencies. In the one case they have 
taken for basis insoluble preparations, on the supposition that the acids of the 
stomach would transform them into soluble salts of easy absorption. In the 
other case, in order not to depend on this solvent action of the gastric juice, the 
secretion of which is deficient in chlorosis, they have resorted to the soluble 
combinations, and they have aimed to come as near as possible to those ferru- 
ginous compounds which are supposed to be the form in which iron circulates in the 
blood, and have given the chloride, the lactate, the albuminate and the pepton- 
ate. 1 It has even been attempted to utilize the iron of the blood globules, and 
haematin and hsematoidin have been administered in a state more or less pure, 
in the form of solution or of pills. The same ideas have led certain experi- 
menters to prescribe in chlorosis preparations of dried and pulverized blood. 2 

If ferruginous preparations are numerous, chalybeate waters are no less so, 
and there is scarcely a town or hamlet in this country which is not credited 
with a mineral spring containing iron among its important ingredients. Paris 
boasts of two such springs, one at Auteuil, the other at Passy. 

[Here follow the details of the principal ferruginous springs of the conti- 
nent, which are omitted in the translation, owing to their being of little practical 
interest to American practitioners. It cannot yet be said that the chalybeate 
spas of this country in variety and in quality, equal those of the continent of 
Europe. We have, however one species of natural ferruginous waters, which is 

1 These are the conclusions of Jaillet's work: 

i. The chloro-peptonate of iron, which is to be considered as the product of the diges- 
tion of ferruginous salts in the stomach and intestine, is a medicament inoffensive to the red 
globules, the stomach, and the digestive tube, whatever the dose employed or the method of 
absorption. 

2. The chloro-peptonate of iron is absorbed and assimilated in the state in which it is 
ingested, undergoing no decomposition either by the gastric juice or by the alkalies of the 
blood. 

3. When once assimilated the chloro-peptonate energizes the phenomena of combus- 
tion and augments the functions of nutrition, all of which finds expression in elevation of the 
temperature, diuresis, augmentation of the products of excretion, and of disassimilation,such 
as urea, phosphoric acid, and the chlorides of the urine. 

4. In fine, by this increase of the combustions of the economy and the heightening of 
the activity of the functions of assimilation and disassimilation, the chloro-peptonate of 
iron, improves the appetite, and during the duration of the ferruginous treatment, if the 
alimentation is not sufficiently restorative there is produced emaciation. On the other hand, 
this loss of weight is largely compensated for by the physiological qualities which the blood 
regains, and which continue after the cessation of the treatment, (a) 

2 See, for example, Guerder's valuable article on " Desiccated Defibrinated Blood," in 
the Therapeutic Gazette for Feb. 15th, 1884. 



(a) Jailet, Etude Physiologique, et Clinique sur la chloro-peptonate de fer. 



236 ON THE TREATMENT OF ANAEMIA. 

unique; there is nothing in Europe like our aluminous waters. These springs 
are sometimes called acid springs, by reason of the free sulphuric acid which 
they contain. They contain also sulphate of alumina and iron. These ferru- 
ginous alum springs are found principally in New York and Virginia. In New 
York we have the Byron Acid Springs and the Oak Orchard Acid Springs. 
The water of these springs is too sour to be drunk without dilution. The Bath, 
Rockbridge, Bedford and Church Hill Alum Springs of Virginia, belong to this 
category. These waters are powerfully astringent and tonic. 

Of sulphuretted mineral waters we have several springs that are regarded 
as ferruginous, notably the Buffalo Springs of Mecklenburg County, Virginia, 
the Minnequa Springs in Pennsylvania. 

Among the saline spas are many which contain iron. The Columbian 
Spring, Saratoga, is a very fine chalybeate water, and is much resorted to by 
anaemic invalids. 

Other chalybeate springs worthy of mention are the Bailey Springs of Ala- 
bama, which are alkaline chalybeate; the Schooley's Mountain Springs, New 
Jersey; Cooper's Well in Mississippi, a purgative ferruginous water, containing 
iron with much sulphate of soda and magnesia; Montvale Springs in Tennessee; 
Beersheba Springs in Tennessee, and Rawley Springs in Virginia. The latter 
is one of our best chalybeate springs, and is a favorite place of resort for anae- 
mic persons. 

The quantity of iron in these chalybeate waters is always small; half a 
grain of carbonate of iron to the pint would constitute a very strong ferruginous 
water. 

The chalybeate waters which prove most valuable are those which contain a 
large amount of free carbonic acid gas. Most of these waters hardly bear 
transportation; unless great care be taken they lose their carbonic acid and de- 
posit their iron. — Trans.] 

By the side of these ferruginous waters are placed the artificial chalybeate 
potions which may render you some service. You can easily make a very 
agreeable effervescent chalybeate water by dissolving potasso-tartrate of iron in 
water artificially charged with carbonic acid gas. The quantity of the ferru- 
ginous salt should not exceed one gramme per quart, and fifteen to twenty 
centigrammes is ordinarily enough for a bottleful of the carbonic acid water. 1 

As for the choice of a ferruginous preparation, everything depends on the 
tolerance of the stomach, and as a general rule it may be said that what form 
of iron suits the best is the best. At the same time, when dyspeptic troubles 
exist, I believe that the soluble preparations are preferable, though no fixed 
rule is possible. All your art will consist in varying the different iron prepara- 
tions, soluble and insoluble, according to the case, and in prescribing that form 

1 A good formula is the following, where you cannot have ready access to a soda foun- 
tain: Take of spring water a wine-bottleful; bicarbonate of soda, one English drachm and 
fifteen grains; potassio- tartrate of iron, fifteen grains; citric acid, one drachm. Dissolve the 
bicarbonate of soda and the tartrate of iron in the water, and add the acid in coarse powder; 
instantly cork and seal the bottle firmly. An agreeable and sparkling chalybeate drink. 
(Miaihe.) 



ON THE TREATMENT OF ANAEMIA. 237 

which will most promptly give augmentation of the globular richness, with the 
least trouble to the digestive functions. 

One cannot then say beforehand what preparation of iron is the most likely 
to suit all cases of chlorosis, and almost any chalybeate may be attended with 
inconveniences. Orfila has indeed shown that certain salts of iron are toxic, 
and the experiments of Hans Meyer and Williams have confirmed this. More- 
over iron almost always causes constipation, more or less obstinate; this con- 
stipation is explained by the presence of iron in the stools, and in abundance 
proportioned to the quantity medicinally taken; it blackens the stools, as you 
are aware, a phenomenon whose explanation is not easy. Baruel attributes it 
to the combination of the iron with tannin in the faeces, but Meyer has shown 
that iron blackens the stools in persons submitted to a milk diet, and Buchheim 
explains the blackening by the formation in the intestines of a sulphuret of 
iron. 

If the dark discoloration of the faeces is no evil, the injury to the teeth oc- 
casioned by the martial preparations is often a serious matter. This is an 
argument in favor of the pill form of iron in preference to the soluble forms, for 
by giving the iron in pills you avoid contact with the teeth. 

But the greatest inconvenience of the ferruginous medication, besides the 
constipation, arises from the gastric disturbance which it occasions, and 
especially the pain, and there are stomachs which will not bear iron in any 
form. This intolerance, however, is often the result of the choice of an unsuit- 
able preparation, or of excess in the dose. I believe, in fact, that physicians 
generally prescribe too large doses. You can, moreover, use as a convenient 
guide the table of Jeannel given below, which shows you the quantity of 
metallic iron contained in each of the martial preparations. 1 

Moreover, in a critical study which I have made of the employment of iron 

1 Jeannel's table to show the quantities of iron contained in ioo parts of the various 
ferruginous preparations: 

PART OF IRON. 

Iron by hydrogen (fer. redact. Quevenne's iron) ioo 

Ethiop's martial (black oxide of iron) 72 

Ferric oxide 70 

Hydrated sesquioxide 59 

Aperient saffron of Mars 51 

Crystallized sulphate of iron 21 

Ferrous lactate (lactate of protoxide) 19 

Dried carbonate of iron (proto-carbonate) 47 

Iodide of iron 18 

Citrate of iron (ferrous citrate) 30 

Ferroso, ferric phosphate 30 

Chloride of iron 34 

Sulphate of peroxide (sesquisulphate) 28 

Potassio- tartrate 21 

Ferric citrate (citrate of peroxide) 22 

Pyrophosphate (citro-ammon. ferric pyrophos.) 18 

Pyrophosphate of iron and soda 20 

(Jeannel, Formulaire Officinal. 2d Ed.; Paris, 1876.) 



238 ON THE TREATMENT OF ANAEMIA. 

in therapeutics, I have proved how insignificant the quantity of iron which the 
blood loses in even the most advanced stages of chlorosis; I have, in fact, shown 
that in the case of a woman weighing 60 kilogrammes, the quantity of iron con- 
tained in the blood does not exceed 2 grammes, and that the most extreme 
anaemia does not lower this figure more than 50 centigrammes. It is well to 
have these facts before you when you give iron preparations, and keep well in 
mind that the renovation of the globules is not proportioned to the dose admin- 
istered. 

Is not- this renovation of globules possible without the administration of 
iron ? Hayem affirms the negative, basing his belief on experiments. For him 
iron is indispensable in the treatment of chlorosis; other medicaments may lend 
their help, but iron alone is capable of augmenting the number of globules and 
their richness in haemoglobin. I do not altogether share this view. I recog- 
nize, with Hayem, that, from a scientific standpoint, iron is the most active of 
medicaments as far as blood renovation is concerned; but I recognize also, and 
this time from a clinical standpoint, that there are a certain number of chlorotic 
patients in whose case every form of iron fails, and will fail to effect a cure, 
while complete restoration may be brought about by means rather hygienic than 
medicinal. 

Moreover, iron does not seem to have any other action than that of restor- 
ing the globules, and this renovation does not take place except where there is 
anaemia. Although Hayem pretends that in the normal state iron may deter- 
mine a veritable " martial plethora," Cutler and Bradford maintain that this 
plethora cannot exist. It has also been affirmed, since the labors of Pokrowsky, 
that iron augments heat production and the excretion of urea, but these are 
rather the indirect effects of the administration of this medication when attended 
with restoration, and consequently with increased appetite and nutrition. 

The adjuvant remedies of chlorosis are numerous. In the first rank is 
placed manganese, which has enjoyed a great reputation. It was in 1847 that 
Hannon, struck with the little result which attended" the ferruginous medication 
with certain chlorotics, conceived the idea of using manganese instead of iron. 
Petrequin, of Lyons, associated iron with manganese in chlorosis, and Trous- 
seau and Pidoux advocated the same treatment. According to the researches 
of Hayem, manganese is not only useless, but even injurious in retarding the 
action of the ferruginous preparations, and it is better to discard it altogether. 

If manganese be, as I am inclined to think, inefficacious, it is not so with 
arsenic, which is a valuable medicament in chlorosis. Arsenic is, in fact, one of 
the most powerful stimulants of nutrition ; it increases the appetite and induces 
embonpoint, and I maintain, despite the negative results attained by Hayem 
and Delpeuche in the enumeration of the globules during the administration of 
arsenic in chlorosis, that in certain cases where iron is not well borne, arsenic 
may be of real service. But I have no faith in the arseniate of iron so much in 
vogue 1 — in giving the preparation you can appreciate neither the effects of the 

1 A preparation much in repute in Germany, and which is given in the dose of from 2 
milligrams to 1 centigram. The following is an old formula, in which the tartarized tincture 
of iron is associated with Fowler's solution : 



ON THE TREATMENT OF ANAEMIA. 239 

iron nor of the arsenic — and if it were necessary to give both remedies at the 
same time, I should give them separately. 

1 pass rapidly by mix vomica, proposed by De Ricci, phosphide of zinc, 
and phosphorus, recommended by Ashburton Thompson, cod liver oil, whose 
action on the globules has been studied especially by Cutler and Bradford, 2 
and I come to two. therapeutic agents which have a real action in the treatment 
of anaemia. I refer to hydrotherapy and serotherapy. 

Hydrotherapy, in stimulating the functions of nutrition, and rendering 
more active the peripheral and central circulation, is a powerful curative agent 
in the treatment of anaemia. In the comparative trials which in my hospital 
service I have made with douches and chalybeates, I ascertained always, as 
Hayem had done before me, that as far as increase of globules is concerned, 
iron is much superior to cold water douches ; but I also ascertained that in 
associating hydrotherapy with the ferruginous medication, the globular renova- 
tion is notably quickened. Hydrotherapy is then a powerful auxiliary, and I 
advise you to make use of it in the treatment of anaemia, following the precepts 
which I gave you in a previous chapter. 3 

^Erotherapy, like hydrotherapy, plays an important part in the treatment 

1$ Tincturae martis tart., 

Fowler's sol., aa 10 gram. 
Dose, 20 drops every day in divided doses. 

2 De Ricci, considering chlorosis as a primitive malady of the nervous system, the 
globular alteration being secondary, has recommended strychnia as the preferable tonic, 
giving it with sulphate of iron. Thompson has vaunted zinc phosphide, maintaining that it 
improves nutrition, and relieves the neuralgia which so often accompanies chlorosis. Cutler 
and Bradford have studied by means of the apparatus of Malassez the influence of iron on 
the richness and number of the globules. Iron does not increase the globules in a healthy 
person, but it does so in a marked manner in anaemic persons. Cod liver oil in healthy, as 
in anaemic individuals, produces augmentation of the red corpuscles, and a slight increase of 
the leucocytes. Fowler's solution causes increase of the red globules in a healthy person, 
but has no action in the anaemic, (a) 

3 Fleury considers hydrotherapy as one of the most active agents in the treatment 
of anaemia and recommends general douches, in the form of the shower bath or the jet 
douche. 

The douches ought to be very short at the commencement, not more than five or 
six seconds. 

Becquerel has seen sixteen cases, rebellious to iron, get well in less than forty-five 
days, by a well-directed hydropathic treatment. 

Beni Barde says that it is necessary to administer the water in a different manner ac- 
cording as you have to do with chlorosis from menorrhagia, or from amenorrhcea. 

In chlorotic girls whose menses are too abundant he counsels cold foot baths of running 
water. The duration of these cold baths ought to be very short, and should not exceed 
several seconds. The water ought to be very cold. When the menses are insufficient, you 
should employ a warm foot-bath with running water, or a very brief cold sitz bath, and when 
you employ the shower bath, the douche must strike the lower part of the body, (b) 



(a) Ashburton Thompson on The Treatment of Chlorosis and Anaemia with Phosphide of Zinc— Ob- 
stetric Journal, No. 24. Cutler and Bradford on The Action of Iron, Cod Liver Oil and Arsenic in Increasing 
the Globular Richness of the Blood.— Am. Jour. Med. Sci., Jan., 1878. 

(5) Fleury, Treatise on ^Hydrotherapy. Paris, 1875. Becquerel, Clinical Lectures on Hydrotherapy. 
Beni Barde, Treatise on Hydrotherapy, p. 408. 



240 ON THE TREATMENT OF ANEMIA. 

of chlorosis, a part which is easily explained when we think of the intimate 
action of oxygen on the haemoglobin. Hence it is that inhalations of oxygen 
have long been recommended in anaemia. While conceding that these in- 
halations energize the digestive functions, and that they augment the quan- 
tity of urine, Prof. Hayem, as a result of his comparative trials, denies that 
they have any direct action on globular formation. 

At the same time these inhalations of oxygen will render you great service 
when you have to deal with chlorosis complicated with digestive troubles. 
Such cases are, unhappily, too frequent, where, too, you meet with obstinate 
anorexia and repeated vomitings. These inhalations remedy the gastric troubles, 
and enable iron tonics to be borne. 

Baths of compressed air act in the same way in the treatment of 
chlorosis, and it is easy to understand the success obtained with these baths 
by Gente, Tabarie, Moutard Martin, Pravaz and Fontaine. You can make 
use of inhalations of compressed air (as is done in my hospital service), and 
exhalations in rarefied air, by means of the ingenious apparatus of my pupil, 
Dr. Maurice Dupont. Without having an action as energetic as the inhala- 
tions of oxygen, or the baths of compressed air, these inhalations of com- 
pressed air energize the respiratory functions, and have an adjuvant and 
favorable action in the treatment of anaemia. For the employ of these dif- 
ferent aerotherapic means, I refer you to what I have said in the previous 
chapters. 1 

By the side of serotherapy we must place out-door air and sunlight; 
and this brings us to the last part of our subject, the hygienic treatment of 
chlorosis. 

While recognizing that iron plays a special part in globular renovation, 
and constitutes the specific treatment of this affection, we must nevertheless 
admit that there are cases where the digestive functions are so disturbed, 
and where the secretion of intestinal juices is so enfeebled that neither 
preparations of iron nor good food can cure them, however judiciously the 
treatment may be carried out. What we are obliged to do is to place the 
patient in an invigorating atmosphere with abundance of pure oxygen, which 
shall stimulate all the functions of the organism. This is especially neces- 
sary in the case of the chlorotics of our large cities, where the determining 
cause of the chlorosis resides, in great part, in the impure air which they 
breathe. 

Therefore, in all cases of rebellious chlorosis do not hesitate to send 
your patients to the country or to the sea-side, or even to the mountains, 
(as Lombard recommends). Make them live out-doors, and in the sunshine, 
and you will attain results which neither ferruginous medicines nor a well- 
selected dietary regimen had enabled you to obtain previously. 

Alimentation, nevertheless, has an important role; not only because health- 
ful nutrition is dependent upon it, but because it is a means of introduction of 
iron into the economy; not to mention those artificial ferruginous foods, as 
bread, or chocolate containing iron; animal food contains this metal in its 

1 Vol. II. On the Therapeutics of Diseases of the Lungs. 



ON THE TREATMENT OF ANEMIA. 241 

most assimilable form, and there is no chalybeate equal to beefsteak. But by 
the side of meat is ranged a great number of alimentary substances, and 
nothing is more curious in this respect than the figures furnished by Bous- 
singault. 

Boussingault, in fact, not only has given us a list of the principal foods 
with the proportion of iron which they contain, but in studying the daily 
rations of the soldier and day laborer, he has shown us that they include from 
six to ten centigrammes of iron and we are enabled to affirm that in the dietary 
of the wealthier classes the quantity of iron is considerably greater. 1 

Unfortunately it is not enough to know that the food contains of itself 
sufficiency of iron to cure chlorosis, it is necessary that these aliments shall be 
digested and absorbed. In the greater number of our chlorotic patients the 
digestive functions are so enfeebled that neither this digestion nor this absorp- 
tion can take place, and hence it becomes necessary to invoke the auxiliary 
influence of pure bracing out-door air, hydrotherapy, and even gymnastics, 
which regulate and arouse the forces of the economy. 

But before terminating this too long lecture, it remains for me to consider 
i 

1 According to Boussingault the daily rations of the sailor and the soldier in France, 
contain 0.0660 to 0.0780 of iron. In the case of the English workingman the quantity is 
greater, attaining the enormous figure of 0.8912 in England, and 0.1090 in Ireland. 

Below is Boussingault's table, showing the proportion of iron in different alimentary 
substances; the proportion being given in decimals of a gramme: 

IOOO PARTS. 

Beef's blood o . 03750 

Swine's blood 0.06340 

Beef's flesh 0.00480 

Veal 0.00270 

Fish (whiting) 0.00150 

Fresh cod fish . o . 00420 

Eggs (of fowls) 0.00570 

Shell fish o .00360 

Fresh beef bones 0.01200 

Sheep's feet (bones) 0.02090 

Wheat bread o . 00480 

White beans o . 00740 

Oats 0.01310 

Lentils 0.00830 

Potatoes o. 00160 

Milk (of cows) 0.00180 

Carrots o . 00090 

Indian corn 0.00360 

Rice 0.00150 

Apples o . 00200 

Spinach o . 00450 

Cabbages (green leaves) o . 00390 

Red wine of Beaujolais (per quart) o . 01990 

Beer o . 00400 

River water (Seine). ¥ 0.00104 

(Boussingault, Comptes Rendus de 1. Acad, des Sciences, t. 74, p. 22.) 

§16 



242 ON THE TREATMENT OF ANJEMIA. 

two important points in the subject which is before us. Ought we to try to 
cure all cases of chlorosis ? Are all cases and kinds of chlorosis 
curable ? Trousseau maintained that there were forms of chlorosis 
which we ought to let alone, and in speaking thus, he meant those 
symptomatic anaemias in the commencement of phthisis; he affirmed that in 
these cases when you administer iron tonics you may cure the chlorosis, but 
you will fatally enkindle the symptoms of pulmonary tuberculosis. 

I believe that this affirmation of Trosseau is an exaggeration. I admit 
with him that ferruginous medication may have its inconveniences, and in 
particular that of predisposing to haemoptysis, but to say that in these cases we 
ought not to treat the anaemia, is to go to the other extreme. We ought on the 
contrary to raise the rate of nutrition as high as possible in persons predisposed 
to tuberculosis, for the more the functions of the economy are feeble and lan- 
guishing, the more the soil becomes favorable for the development and multi- 
plication of the bacillus tuberculosis. We ought then to treat these false chlor- 
oses, but especially to employ hygienic means in these cases. 

Are all forms of chlorosis curable? Assuredly not. There are anaemias 
•called pernicious, essential anaemias which resist all treatment. You will see these 
pernicious anaemias, which Immermann and Biernier have well studied, super- 
vene as a sequel of prolonged lactation, and I have seen them so arise in my 
infant hospital. That which most markedly attracts your attention in these 
cases, apart from the enormous decrease of blood corpuscles, and the disap- 
pearance of haematoblasts, is the anorexia which nothing can overcome, a 
subject concerning which I have already spoken under the head of diseases 
of the stomach. 1 [See Vol. I. Part 2.] 

At the necropsy nothing is noted but fatty degeneration of the different 
organs. Is this fatty disease primary, or is it secondary ? This is a question 
which we cannot answer. What has struck me particularly in these cases is the 
fatty transformation of the pancreas, a morbid condition which must play an 
important part in the digestive troubles. Whatever may be the pathogenesis, 
everything has been tried, ferruginous preparations, inhalations of oxygen, 
country air and exercise, the most carefully directed dietary regime, and every- 
thing has failed. I have even attempted, not merely the alimentary regimen of 

1 Immermann, of Bale, and Bierner have studied a disease which they have described 
as progressive pernicious anaemia, and which is characterized especially, by a haemorrhagic 
diathesis, and by febrile attacks. In this anaemia all the elements of the blood diminish in 
quantity ; at the autopsy is observed fatty degeneration of the heart, of the muscles and of 
the different viscera. 

Quincke has found in a case of pernicious anaemia, a considerable quantity of iron in 
the liver, in the kidneys and in the pancreas. In the liver the quantity of iron is as great as 
7 grammes, or a quantity larger than the sum total of iron in the economy in a normal state. 
He maintains that this iron is a result not of ferruginous treatment, but of the destruction 
of corpuscles, (a) 



(a) Immermann, Ueber Progressive Perniciose Anemie. Quincke, Zeitschrift den Andenken an Alb. 
Vhaller. Dargebracht, Bern, 1877. Destree, On Progressive Pernicious Anaemia, Jour, de Med. de Bruxelles, 
August, 1882. Jacquemart, On Progressive Pernicious Anaemia, Jour, de Med. de Bruxelles, July, 1882, 
Lepine, Union Med., Nos. 114 and 115, 1876. 



ON THE TREATMENT OF ANAEMIA. 243 

Brown-Sequard, but forced feeding with the oesophageal sound, with, however, 
indifferent results. It may be truly said that the alimentary canal, profoundly 
affected in all its glandular elements, is incapable of fulfilling its functions of 
digestion and assimilation. 1 

Transfusion has been recommended in these inveterate cases, and I have 
even seen it practiced by my master Beheir for anaemia, and with good 
results. 2 I believe, in fact, that in true pernicious anaemia transfusion, although 
not conferring any very lasting benefit, may nevertheless lengthen out the life 
of the patient. I think, however, that the benefits of the operation are hardly 
commensurate with the risks. 

There are then, gentlemen, chloroses which we cannot cure; happily these 
are exceptional, and by following out the precepts which I have given, you will 
meet with success in the greater part of your cases. 

It remains for me to indicate how you should modify your treatment 
according to the forms of anaemia which you have to treat. I will be brief, as 
this lecture has already been too long. It is especially in essential anaemia that 
the therapeutic rules which I have traced are applicable. This chlorosis pre- 
sents itself, as far as menstrual troubles are concerned, under two states; some- 
times there is amenorrhcea, sometimes menorrhagia. When the menses are 
very profuse it is necessary to be chary in the administration of ferruginous 
medicines which increase the haemorrhage, and it is well to employ concur- 
rently ergot or ergotine. 

When you have to treat symptomatic anaemia, and in particular anaemia 
from loss of blood, good food and out-door air may be sufficient to bring about 
a cure. As for the anaemias which accompany cachectic states, they are not 
amenable to ferruginous treatment, and our efforts should aim to combat the 
first cause of these cachectic states. 

Such, gentlemen, are the therapeutic rules which I desired to give you as 

1 Brown-Sequard has proposed to treat functional dyspepsia, anaemia, chlorosis by a 
sort of forced or frequent feeding, which consists in making the patient eat a great many 
times a day, even as many as sixty times, (a) 

2 Not only has transfusion been proposed in cases of pernicious anaemia, but it has 
been applied to the treatment of grave chloroses. 

Neusbaum, from 1861 to 1864, cured three patients by the injection of large doses of 
defibrinated blood, 360, 450, and 550 grammes. 

Hasse, in 1872, obtained two successful results by injecting thirty and ninety grammes 
of defibrinated blood. 

Casse, in 1873, practiced injections of defibrinated blood in three cases of chlorosis, 
using 80, 75, and 25 grammes. 

Roussel has injected in one or tv/o instances, 250 grammes, and Christoforis, 600 
grammes. 

In fine, Heyfelder has injected arterial blood in the veins of a chlorotic woman. 

To sum up, out of twelve cases of grave chlorosis, treated by transfusion, the result 
was successful in ten. 



(«) Brown-Sequard, On a New Treatment of Functional Dyspepsia, Anaemia and Chlorosis in Archives 
of Scientific and Practical Medicine, No. i, 1873. 



244 ON THE TREATMENT OF ANAEMIA. 



touching anaemia. In the next lecture I shall continue the study of the treat 
ment of general diseases, and shall make my subject the treatment of acute 
rheumatism. 






ON THE TREATMENT OF ACUTE RHEUMATISM. 

Summary — Acute Articular Rheumatism — Natural Evolution of Rheumatism — Expectancy in 
Rheumatism — Divers Treatments of Rheumatism — Antiphlogistic Treatment — Blood- 
letting — Antimony — Anti-febrile Medication — Quinine — Local Treatment — Revulsive 
Method — Vesicatories — Anti-rheumatic Balms and Liniments — Hypodermic Injections 
— The Specific Medication — Alkalies — Salts of Sodium — Salts of Potassium — Acid 
Medication — Ammoniacal Salts — Propylamine and Trimethylamine — Cyanides — Sali- 
cylic Acid — History — Administration of Salicylate of Soda — Advantages and Disadvan- 
tages of Salicylate of Soda — Indications and Contra-indications of the Salicylate 
Medication — Treatment of Local Rheumatism — Balneo-therapy in the Treatment of 
Rheumatism — Sudorifics — Vapor Baths — Medicated Vapor Baths — Sulphur Baths — 
Resume of Treatment — Treatment of the Complications of Rheumatism — Treatment of 
Cerebral Rheumatism. 

Gentlemen: The plan which I have marked out for these lectures in 
practical medicine does not allow me to discuss the numerous theories which 
have been prevalent respecting the nature of rheumatism.' I shall, therefore, 
enter at once upon the subject, which is the treatment of this disease in its 
acute articular and peri-articular forms. 1 I shall then examine the various 
modifications to which therapeutic rules must conform when rheumatism affects 
tissues and organs other than the joints. 

Manifesting itself by severe pains in the joints, and intense febrile symp- 
toms, acute rheumatism has been the subject of a variety of treatments. I shall 
trace for you, as rapidly as possible, the history of kinds of medication formerly 
in vogue, and then set forth at some length those which are to-day generally 
employed. 

Clinical medicine has, in fact, made great progress in the treatment of 

1 The theories on the nature of rheumatism may be referred to four heads: The embolic 
doctrine; the parasite doctrine; the neuro-trophic doctrine; the humeral doctrine. 

According to the first hypothesis, endocarditis is always primitive, and the inflamma- 
tions of the joints depend on emboli which lodge in the vessels of the articular synovial 
membranes ; these emboli are constituted of solid particles, taking their origin in the diseased 
valves. 

2. The doctrine of infection is very much like the other; it has been maintained by 
Klebs. According to this view, the embolus is not formed in the heart, but results from the 
penetration into the blood of figured ferments (living microphytes), which are supposed to 
enter the system through the orifices of the skin dilated by the perspiration. 

3. The neurotrophic doctrine has been defended by Heymann; it is based on the pro- 
duction of the arthrites under the influence of lesions of the nervous system. According to 
this theory, cold acts on the nervous centres and determines modifications in the trophic 
centres which preside over the joints. 

4. There are two hypotheses concerned in the humeral theory. According to the one, 
it is uric acid which predominates, and rheumatism is assimilated to gout; according to the 
other, the peccant humor is lactic acid; this theory has been maintained by Richardson and 
Rauch (a). 



(a) Bouchard, Maladies par ralentissement de la nutrition, p. 333. Paris, 

245 



246 ON THE TREATMENT OF ACUTE RHEUMATISM. 



rheumatic fever, and we are in position to-day to affirm that we possess a heroic 
curative agent for this affection, and which answers to the desiderata formulated 
with so much sagacity by Chomel, and reiterated in the remarkable article 
which my colleague, Ernest Besnier, has devoted to rheumatism in the Diction- 
naire Encyclopedique? We can then say that we have a medication for rheuma- 
tism, applicable to all acute febrile cases, which merits the appellation of specific. 
I refer to the salicylic treatment of rheumatism. 

But before attaining this goal, therapeutics has had a route to traverse in 
which it has been guided by considerations based on the ideas which were 
entertained of the precise nature of rheumatism. Various methods of treatment 
the more readily found favor since by the natural march of the disease acute 
articular rheumatism spontaneously undergoes evolution toward recovery. I 
have in this particular shown in a communication made to the Medical Society of 
the Hospitals, that acute rheumatism presents itself under three forms — benign, 
moderate and grave. In the first form the disease naturally finishes its course 
in eight or ten days ; in the second, oftenest observed, the duration is at least 
three weeks ; in the grave forms the entire period of the disease is reckoned 
by months rather than by weeks. 2 

You understand then that physicians who have proposed certain treatments 
for rheumatism, have invoked in favor of the medication employed, what was in 
reality but the natural evolution of the malady, and it has been the easier for 
them to do this, that it is impossible for us at the onset of an attack to say what 
shall be the normal duration of the case which we have before our eyes. There 
has even resulted from this fact an application of the expectant method to the 
treatment of rheumatism, and Honore has made himself defender of this- 
method, which to-day has but few partisans. 

Formerly, in the multiple manifestations of the disease, reasons were sought 
for the different kinds of treatment counselled in such cases. So, according as 
one considered rheumatism as an inflammation or was desirous of combating 
the febrile symptoms which accompanied it, or the articular pains which charac- 
terized it, or the rheumatismal virus itself, different remedial agents have been 
put in usage, which may be arranged in four groups — antiphlogistic medica- 
tion, antifebrile medication, local medication, and specific medication. 

(i) The antiphlogistic medication applied to rheumatism, comprises espe- 
cially the treatment by bloodletting and tartar emetic. Vaunted of old by 

1 " We are to look for a medicine which, out of a total of 30 or 40 patients affected with 
rheumatic fever, will bring about a cure in a mean of 14 days. Then there would be no 
doubt as to the efficacy of the remedy. Such a remedy has long been sought for in vain." — 
Chomel. 

"In the present state of science there is no anti-rheumatic medication, in the true sense 
of the term. There are only therapeutic agents applicable to rheumatic patients, according 
to the general and common rules of therapeutics." — Ernest Besnier in Diet. Encyclopedique. 

2 Dujardin Beaumetz — Critical Reflections on Expectancy as a Method of Treatment of 
Acute Articular Rheumatism, (a) 



. 



(a) i^Bull et Mem. de la Soc. Med. des hop. de Paris, 2d Serie, t. xii, p. 184, 1875.) 



ON THE TREATMENT OF ACUTE RHEUMATISM. 247 

Sydenham, restored to honor by Broussais, and applied with extreme rigor by 
Bouillaud, 1 bleeding in rheumatism is now completely abandoned, and this for 
several reasons. First, because contrary to the opinion of Bouillaud, it dimin- 
ishes neither the intensity nor the duration of the disease, as Cullen long before 
the time of Bouillaud remarked. Secondly, because as Gubler observes, rheu- 
matism is itself an anaemiating disorder, and determines an alteration of the 
blood characterized particularly by an a globular condition which sometimes 
persists. By the side of venesection we must place tartar emetic in large doses, 
once vaunted by Bayle, but now for a long time abandoned, in accordance with 
the just observations of Dance. 2 

(2) Antifebrile medication. In the first rank of antifebrile medicaments, 
we must place sulphate of quinine, and especially quinine in large doses, a kind 
of treatment which has been extolled by Briquet and Monneret. 3 This medica- 
tion consists in giving from two to four grammes of sulphate of quinine a day, 
and under the influence of these doses there is often observed a lull in the pain, 
and above all, a decline in the fever. Quinine has been accused of being the 
cause of grave cerebral accidents. This is a mistake, for these accidents which 
are among the complications of acute rheumatism, may occur apart from all 
medication. To-day, since the discovery of the salicylic treatment, quinine 
occupies but a secondary place in the therapeutics of rheumatic fever. 

(3) As for local treatments they are very numerous, and consist especially 
of revulsive applications, soothing embrocations, subcutaneous injections, and 
the use of topical appliances that are more or less complex. 

The revulsive method is very much employed. Little applicable to acute 
articular rheumatism by reason of the mobility of the symptoms, it gives re- 
markable results in the local arthrites, and I shall have more to say about it 
when I come to speak of chronic rheumatism. 

At the same time it has been proposed to treat acute articular rheumatism 

1 This is Bouillaud's method of treating acute rheumatism : First day. On the arrival 
of the patient at the hospital at the evening visit, blood is let to the amount of twelve ounces. 
Second day. Bloodletting to the amount of from nine and one-half to twelve ounces, 
morning and evening, and in the interval, one application of leeches, or better still, wet 
cups around the joints. The local bleeding ought to be to the extent of nine, twelve, and 
even fifteen ounces. Third day. A fourth bleeding of from nine to twelve ounces, and 
local bloodletting in about the same quantity. In case the patient is better, stop the 
bloodletting. Fourth day. If the remission is not decided, practice another bleeding of nine 
ounces. In the fifth, sixth, and seventh days which follow, if the rheumatism is grave, 
repeat the bloodletting. Bouillaud pretends that by this treatment the mortality of rheu- 
matism is diminished, and the disease is prevented from becoming chronic and that the 
duration of the disease is shortened from one to two weeks, (a) 

2 Bayle, Bibliotheque de Therap II. Dance on the Employ of Tartrate of Antimony 
in the Treatment of Acute Articular Rheumatism. (Arch. Gen. de Med., 1840). 

3 Vinay, Treatment of acute articulate rheumatism by sulphate of quinine. {These de 
Paris, 1841.) (Briquet. Bull, de l'Acad. de med., Paris, I842, t. viii, p. 152 et 898.— Monne- 
ret, Compendium de med. prat., art. Rheumansme, t. vii, p. 390. 



(a) Bouillaud, Traite clinique du rheumatisme articulaire, Paris, 1C4C 



248 ON THE TREATMENT OF ACUTE RHEUMATISM. 

>by blisters around the joints, and Dechilly, Lasegue, Fernet, in France, Herbert 
Davies, Jeafferson, Greenhow, in England, Frantzel, in Germany, have vaunted 
the good effects of this method, which has found, it must be owned, few par- 
tisans in our own country. 1 

Next in order come the local anodyne preparations. The number of these 
pomades, liniments and lotions is innumerable, from the opodeldoc of ancient 
repute and the complex balm of Fiorvanti, 2 to embrocations of steel and other 

1 Dechilly (Bull, et Mem. de l'Acad. de Med., 1870, t. xv, p. 665) proposed in 1850 to 
treat articular rheumatism by blisters made to surround the affected joints, and Herbert 
Davies, of London, recommended to apply the blisters not upon the joints, but in the 
vicinity. This treatment was said to assuage the pain and to abridge the duration of the 
rheumatism. Jeafferson and Greenhow, in England, have derived benefit from the so-called 
method of Davies ; in France, Lasegue and Fernet have employed it. This is Lasegue's 
method : from the commencement of the pain and swellii.g, strips of blistering plaster from 
an inch and a half to three inches wide and long enough to surround the limb like a bracelet 
or garter, are applied half an inch or so above and below the painful joint. In Germany 
Frantzel has also adopted the practice of Davies. (a) 

' 2 Below are several formulae of anti-rheumatic liniments: 

1. Pomade of Gueneau de Mussy: 

R Extract of hyoscyamus, ) .... 

K a u 11 i r aa 3 parts. 

belladonna, \ J v 

" " hemlock 4 " 

" " Axunge 40 " 

M. Ft. pomade. 

2. Liniment of turpentine and acetic acid (Pharmacop. Br.): 

]$ Spts. tereb 15 parts. 

Acetic acid , 15 

Camphor 3 " 

Olive oil 12 " 

M. Fiat linimentum. 

3. Rheumatic liniment: 

T* Oil of Cedar 

Fluid Ext. Hyoscyamus J-aai part. 

Opodeldoc, 

M. Fiat linimentum. 

4. Calmative liniment: 

$ Tinct. opii , "] 

Chloroform ! .... . . 

T . t >aa 1 part. 

Tinct. aconite r 

Sweet oil J 

M. Fiat linimentum. 
The formula for opodeldoc (tinct. saponis co) is too generally known to require repro- 
duction here. 

The balm of Fiorvanti is a very complex terebenthinate preparation. It consists of 
seventeen different ingredients: among them turpentine, elecampane, amber, storax, galba- 
num, myrrh, aloes, ginger, cloves, cinnamon, nutmeg, alcohol. 

The balm of steel consists of steel needles dissolved in nitric acid, to which is added 
olive oil and alcohol. 



1 



(«) Davies, On the Treatment of Rheumatic Fever, in its Acute State, Exclusively by free Blistering, 
London, 1864. — Frantzel, Charite-Annalen, Berlin, 1874 — Fernet, Du rheumatism articufaire aigu et de son 
traitement par les vesicatoires (Arch. g£n. de med., t. vi, p. 531). 



ON THE TREATMENT OF ACUTE RHEUMATISM. 249 

absurd formulas which are patented and advertised as infallible for aching 
joints. These preparations have really a very limited action, and if they 
do good it is due more to the rubbing by which they are applied than to the 
absorption of any of the analgesic principles of which they are composed. 

By the side of these revulsives and these soothing preparations we should 
place subcutaneous injections. Dieulafoi has proposed to calm the pains in the 
joints by hypodermic injections of water, for which, however, of late, phenic 
acid injections have been substituted, as employed by Kunz 1 especially, and 
Senator, Mader and others, in Germany. Badia and Heyfelder have used col- 
chicine subcutaneously. This practice has not had many partisans, and I am 
not aware of anyone in France advocating these subcutaneous injections. 
When I come to speak of chronic rheumatism I shall have more to say about 
this kind of local treatment, and I hasten now to: 

(4) The specific treatment of the disease under consideration. 

Thinking that there existed an alteration of the blood in rheumatism, and 
that this alteration consisted, as in gout, in the predominance of certain acids, 
and of uric acid in particular, or even supposing that it was possible to modify 
the fibrine of the plasma, clinicians have employed in this affection the alkaline 
treatment, at the head of which stand the salts of soda, and especially the 
bicarbonate of soda, which English practitioners have administered in large 
doses, till as much as an ounce daily was taken. A remedy very popular in 
gout, the benzoate of soda, has also been used in acute and sub-acute rheuma- 
tism, and Senator is the leading advocate of this medication. 2 

Some authorities have preferred the salts ot potash to the salts of soda. 
Thus, in England, Garrod, Dickinson and Chambers give from an ounce to an 
omice and a half of bicarbonate of potash daily to their rheumatic patients. 3 

1 Kunz practices around the joints from two to six injections, with a Pravaz syringe, of 
a one-per-cent. solution of carbolic acid. This treatment, he alleges, calms the pains. 
Senator has also witnessed local alleviation from these injections. Mader makes use of a 
two-per-cent. solution, injecting one cubic centimetre. Badia administers colchicine in the 
same way, injecting in the neighborhood of the joints two milligrammes in one gramme of 
water. Heyfelder, of St. Petersburg, also favors the same treatment. These injections 
produce quite severe local irritation, but they hasten a cure, even in the case of chronic 
rheumatism, according to these authorities. 

- Senator employs benzoic acid and benzoate of soda in acute rheumatism. He gives 
the latter in doses amounting to ten or twelve grammes a day. He considers benzoate of 
soda an auxiliary of salicylic acid, (a) 

3 Garrod gives two scruples (3ij) of the bicarbonate of potassa every two hours, day 
and night, till the fever is gone. Chambers' practice is to give one scruple of bicarbonate of 
potassa, every hour, in camphor- water. In England it is also a common custom to prescribe 
the citrates, tartrates, and acetates of potassium and sodium in the medium dose of fifteen 
grains every two hours, so that three or four drachms shall be taken during the twenty- four 
hours. Dickinson affirms that any quantity less than two drachms a day, is of no effect 
whatever, and he recommends to give from one ounce to an ounce and a half of potash 



(a) Senator, Uber die wirkung der benzoesaure bei der rheumatischen pol yarthrites. Zeitschrift iiir Kl. 
Med., 1875, t. 1, p. 243. 



250 ON THE TREATMENT OF ACUTE RHEUMATISM. 

Some prefer the citrates, tartrates, or acetates of the fixed alkalies, in quantities 
of from half an ounce to an ounce in the twenty-four hours. Nitrate of potash 
has been administered in similar doses, and Gendrin, Martin Solon and Seux, 
in France, and Brocklesby, Macbride and William Whytt, in England, stand as 
the representatives of this treatment. 4 

In opposition to this alkaline medication we must note the acid treatment 
of rheumatism, and particularly the treatment by lemon juice. Proposed by 
Owen Rees, 5 adopted by Donald Dalrymple, 5 Hector Pelletier 5 of Montreal, 
Perkins of Brussels, and by Ciraud, 6 this lemon juice medication is not so 
widely different from the treatment by alkalies as one would suppose, for, as 
Golding Bird observes, lemon juice is nothing more nor less than supercitrate 
of potash. 

I myself believed that I had found several years ago an alkaline compound 
containing ammonia for its base, which has an action truly specific in the treat- 
ment of acute articular rheumatism; I refer to those ammoniacal sails, propyla- 
mine and trimethylamine. 

It was in 1872 that I commenced the trial of these preparations in the 
Maison Municipalede Sante, and on the 10th of January, 1873, 1 communicated 
the results to the Societe des Hopitaux. From this time, and as a consequence 
of this report, propylamine and trimethylamine have been the subject of numer- 
ous labors in France and elsewhere, and Aissa Hamdy, Peltier and Bourdet, in 
France, Phillipo Caesari and Namias in Italy, Spencer in England, Mount in 
Canada, Loever and Leo in Germany, have published the results of important 
investigations on these remedies. Despite all these efforts this medication has 



salts per day. He gives these alkalies in the following manner: Every four hours the 
patient is made to take a draught containing one drachm of bicarbonate of potash and one- 
half drachm of acetate of potash in spirits of mindererus. 

According to the statistics published by Basham and by Chambers, this medication 
protects from cardiac complications, (a) 

4 According to Martin Solon, nitrate of potassa, given in large doses in acute articular 
rheumatism, causes resolution in from four to ten days, and oftener in seven than in ten. It 
manifests its action in the most severe cases as well as in the mildest. He administers the 
nitrate in the following way: The patient is made to take, every few hours, from two to 
four drachms of nitre in a cup of some bitter infusion, the time for each dose being so regu- 
lated that from half an ounce to two ounces may be administered per day; ordinarily a quantity 
of one ounce per diem is not exceeded. 

The salt may be given in lemonade, in chamomile tea, or in any other simple herb 
ptisan. Basham has employed the nitrate of potassa in still larger doses than the foregoing, 
i. e., exceeding two ounces a day, but he makes especial use of the salt externally in strong 
solution, saturating with it felt or wadding, with which the inflamed joints are swathed, (b) 

5 Owen Rees, Edinb. Med. Jour., Aug., 1845. Donald Dalrymple, Lancet, Sept., 
1850. Hector Pelletier, Montreal Medical Journal, April, 1853. Ciraud, Jour, des Conn. 
Med. Chir., July, 1851. 



(a) Garrod, Lancet, March 3, 1857. Behier, du Traitment, du Rhumatistn, Bull, de Ther. t. lx.xxix., p. 
529, 1875. 

(6) Martin Solon on " The Employ of Nitrate of Potassa in Large Doses in the Treatment of Acute 
Rheumatism," 1843. Basham, Union Med., March, 1850. 



ON THE TREATMENT OF ACUTE RHEUMATISM. 25l 

been abandoned, and this more on account of the difficulty of obtaining a re- 
liable preparation than for any other reason. 1 

Although I had effected the substitution of chlorhydrate of trimethylamine 
for the impure propylamine extracted from cod-liver oil and herring brine, and 
though I showed the chemical differences which separate the two amides, I 
recognize the fact that we have not a medicament possessing always the same 

1 Wertheim discovered propylamine in 1850 as a product of the reaction of potassa 
on narcotine; the same year Anderson obtained an identical compound from codeia, hav- 
ing the formula C6H9N, to which he gave the name it now bears. In 185 1 Anderson's 
propylamine was found in herring brine, and Desaignes discovered it in chenopodium 
vulgaris. The labors of Hofmann and Wurtz have brought to light the differences which 
exist between the three amides which have the same atomic constitution — propylamine, 
ethylo-metylamine and try-methylamine — and which result from the substitution of alcohol 
radicals for hydrogen, as may be seen in the following table: 

Pr °P^ C6 £ 7 ) N = C6H 9 N 

Tj X (prophylamine) 

Ethyl C4H6 ) N = C6H 9 N 

Methyl C2H3 ) (ethylo-methylaminej 



Methyl..... ...... C2H3 ) N = c 



Methyl C2H3 

Methyl C2H3 



^tri-methylamine) 



Awenarius, of St. Petersburg, in 1856, was the first to employ propylamine, obtained by 
him from cod-liver oil, in medicine. Other Russian physicians, as Nelinbin and Jean, of 
Kaleniczenko, subsequently made successful use of it as a medicament. 

In 1872, John Gaston, in the United States, reported the results of his experience with 
propylamine in the treatment of acute rheumatism. Lagrange, in France, about the same 
time, made trials of tri-methylamine in the same disease, but the subsequent wide-spread 
usage of these amides in rheumatism is chiefly due to the communication of Dujardin- 
Beaumetz to the Societe Med. des Hopitaux in 1873. (a) 

Dujardin-Beaumetz showed that propylamine from herring brine is nothing but tri- 
methylamine, and he substituted for these commercial propylamines chlor-hydrate of try- 
methylamine, which he administered in the dose of one gramme daily. 

The clinical experience of Dujardin-Beaumetz, Namias and Aissa Hamdy has shown 
that try-methylamine lowers the pulse and temperature, and diminishes the secretion of urea 
and the number of pulsations. It is, according to Pelletier, who assigns it a place between 
digitalis and quinine, a neurocardiac medicament. 

Martineau has pretended that the ammoniacal salts have the same action as tri-methyl- 
amine. Dujardin-Beaumetz has experimented comparatively in animals with chlor-hydrate 
of tri-methylamine and chloride of ammonium, and he has shown that if these two medica- 
ments lower the pulse and temperature, chlor-hydrate of try-methylamine never produces, 
even in large doses, the convulsive accidents which are produced by chloride of am- 
monium. Laborde has repeated the experiments of Dujardin-Beaumetz ; he maintains that 
chloride of ammonium and chlor-hydrate of tri methylamine ought not to be arranged 
among antipyretics, and that they have a special action on the spinal cord, and that the salt 
of ammonium alone produces convulsions. 



(a) Dujardin-Beaumetz, On the Comparative Therapeutic and Physiological Action of Muriate of Am- 
monia and Chlor-hydrate of Tri-methylamine, Gaz. Med. de Paris. No. 26, 1873. On Propylamine and Tri- 
Methylamine m the Treatment of Acute Articula Rheumatism, in Gaz. Med des Hop., Jan. 16, 1873, and 
Gaz. Hebd., 1873, Nos. 13, 15 and 16. 



252 ON THE TREATMENT OF ACUTE RHEUMATISM. » 

composition. But the dominant reason for the abandonment of trimethylamine 
was the discovery of a substance much more effective in the treatment of rheu- 
matic fever, namely, salicylic acid. 

Trimethylamine, in fact, had no curative action except in rheumatism of 
moderate intensity, and in these cases it procured alleviation of the pain and 
cessation of the fever, just as does salicylic acid, but it failed in the severe 
forms. Luton's specific treatment of acute rheumatism by the cyanides, and 
cyanide of zinc, in particular, has also shared the same abandonment, as well 
as the veratrum viride medication proposed by Heuser; the salicylic acid treat- 
ment has deservedly superseded them all. 

The application of the salicylic preparations to the treatment of acute 
articular rheumatism was the result of empiricism, and even to-day, as you will 
see as I go on, we cannot explain by the physiological properties of these 
preparations their specific effect in the treatment of rheumatism. 

Employed from time immemorial in the treatment of fever and ague, willow 
bark (salix alba) had also given good results in certain cases of rheumatism, 
but these were lost sight of, and notwithstanding the discovery of salicin in 1829, 
this crystalline principle was not used in the treatment of rheumatism. 

It was Strieker, who, in 1876, first made therapeutic use of, not salicin, 
but salicylic acid, which Kolbe and Lauteman had just discovered by way of 
synthesis by acting on phenol. 1 

What was the idea which directed Strieker in the administration of salicylic 
acid in rheumatism? Did he believe that the anti- fermentative properties 
which had just been discovered in it were applicable to this disease? Did he 
think that it would do good, like quinine, by its anti-pyretic action? We do 
not know. At any rate, he showed quite conclusively that in administering 

1 In 1827 Leroux, a pharmacist of Vitryle Francois, discovered salicin in willow bark. 
A few years later appeared Blaincour's treatise on the employment of salicin in inter- 
mittent fever. 

In 1836 Peria obtained salicylic acid by the action of potassa on spiraea ulmaria (queen 
of the meadow). Then Kolbe and Lauteman obtained it by way of synthesis, by passing 
CO2 into phenol containing a little sodium. Salicylate of soda is thus obtained at the 
present day. 

In 1876 Kolbe and Meyer demonstrated the antiseptic action of salicylic acid, and it 
came into use for dressing wounds. The same year Strieker employed salicylic acid in acute 
rheumatism, and called attention to the rapid curative action of the medicament, which was 
especially noticeable when 50 centigrammes (7-^ grains) were given every hour. At the same 
time that Strieker counselled salicylic acid in rheumatism, Maclagan made trial of salicin, 
and quite a discussion arose as to which was preferable, Maclagan claiming remarkable re- 
sults from salicin. 

In 1877 G. See communicated to the Academy of Medicine his observations on the 
treatment of rheumatism by salicylate of soda and showed the advantages of the sodium 
salt over salicylic acid. From this date the salicylate of sodium treatment became generally 
adopted and medical journalism has swarmed with treatises on this particular part of thera- 
peutics. 



(a) Strieker, Berlin. Klin. Wochen., Jan., 1876, No. 1. Maclagan, Lancet, 1876-77, etc. Blaincour, 
These de Paris, 1830, No. 235. G. See, On the Treatment of Rheumatism by Salicylate of Soda, Academy de 
Medicine, 1877, 2d Serie, t vi Nos. 26 and 27. 



ON THE TREATMENT OF ACUTE RHEUMATISM. 253 

salicylic acid in the dose of fifty centigrammes every hour, you may throttle 
rheumatism in its march, and complete its evolution in three or four days. 1 

I did not hesitate, when I learned of Strieker's success, to test the new 
treatment in the wards of my hospital, and I obtained, like him, remarkable 
effects. One of my pupils, Dr. Anger, whom I have since then had the misfor- 
tune to lose, has recorded in his thesis the principal points in this experimenta- 
tion. 

At the same time Prof. Germain See, who was making trial of Strieker's 
method of treatment substituted for salicylic acid the salicylate of soda, and 
published the results of his clinical experience in his important communication 
to the Academy of Medicine, June 26th, 1877, and despite the efforts of Mac- 
lagan to bring the profession back to salicin, it is the salicylate of sodium which 
is to-day universally employed. 2 

How ought you to conduct this salicylic medication ? What are its disad- 
vantages ? What are its effects ? These are points which remain for us to 

1 Salicylate of sodium, administered to the human subject in large doses, determines an 
irritation of the digestive tube. After a dose of five grammes (75 grains) there supervene buzz- 
ings in the ears, or roarings, with sometimes brain troubles and delirium, lowering of the pulse 
and temperature. Salicylic acid is rapidly eliminated in the urine, in the form of salicyluric 
acid. According to Lecorche and Talamon, salicylic acid considerably augments the excre- 
tion of urea and uric acid, an augmentation which continues for three or four days; then the 
excretion progressively falls, sometimes quite suddenly. There is also an increase of the 
excretion of phosphoric acid. Several explanations have been given of the action of salicy- 
late of sodium in rheumatism. Some have attributed it to a special influence on the sensi- 
bility, but the experiments of Bochefontaine on animals have shown that salicylate of soda 
has no action on normal sensibility, and even if it had, it would be difficult to show why it 
should act in acute articular rheumatism, and not in gonorrhceal rheumatism. It has been 
claimed that this medicament owes its power to a special influence on the vaso-motor system, 
exercising a constrictive action on the dilated vessels of the synovial membrane. This is all 
pure hypothesis. Oltramare thinks on the other hand that it has a vaso-dilator action. The 
diuretic, also the anti-pyretic effect of this medicament has been invoked to explain its 
remedial action in rheumatic fever, while Binz has put forth the opinion that it acts directly 
on the living protoplasm. Vulpian proposes the following explanation: The analgesic, 
diuretic, vasomotor and anti-pyretic properties of salicylic acid cannot explain its specific 
action in rheumatism. It does good by acting directly on the articular elements, bringing 
them back to their normal state, and if one does not observe the same curative effects in 
gonorrhceal rheumatism, and in chronic rheumatism it is because the anatomical lesions are 
different, (a) 

' 2 Maclagan claims that salicin is less disagreeable than the salicylate and is much 
better tolerated. His method of giving it is as follows: Thirty grains an hour till an ounce 
is administered, that is, sixteen hours. At the end of this time the pain is generally gone, 
and the temperature normal or nearly so. Then thirty grains every three hours till the 
second ounce is taken, and finally the same dose three times a day for eight or ten days, {b) 



(a) Petit, on '" The Employment of Salicin, Salicylic Acid, and Salicylate of Soda in Therapeutics." 
Bull, de Ther., t. xci, p. 454 and 508, 1876. Vulpain, on " The Mode of Action of Salicylate of Soda in Acute 
Articular Rheumatism," Bull, de Ther., Paris, 1881, t. c. p. 97. Lecorche and Talamon, on "The Action of 
Salicylate of Soda on the Urea, Uric Acid and Phosphoric Acid of the Urine, in Acute Rheumatism." Revue. 
Mens, de Med. et Chir., March, 1880. Anger, on " The Treatment of Rheumatism by Salicylic Acid," These 
de Paris, 1877. 

(b) Maclagan, on " The Treatment of Rheumatism by Salicin and Salicylic Acid. Lancet, June 21, 1879. 



V! 



254 ON THE TREATMENT OF ACUTE RHEUMATISM. 



study. You prepare with salicylate of soda solutions more or less dilute which 
you administer to the patient. These solutions have a rather disagreeable taste, 
which is remedied to a certain extent by giving the medicine in milk. Here is 
the formula which I generally use: 

3 Salicylate of soda . 15 grms. ( § ss) 

Water 250 grms. ( § viij and 3 ijss). 

M. Signa. A tablespoonful pro re nata. Each dose should contain 
one gramme of the salicylate. 

The question of dose plays an important part in the results attainable by 
this medication. Strieker was right in asserting that it is necessary to admin- 
ister the salicylate of soda every hour till complete cessation of the rheum- 
atism. You must give large doses, and proportion them to the gravity of the 
affection. 

I am accustomed, in rheumatisms of moderate intensity, to administer 
daily from 4 to 6 grammes (1 to 1% drachms) of salicylate of soda, in fractional 
doses, two hours apart, and if by the second day I obtain no abatement of 
the pain and fever, I increase the dose so that the patient shall take 10 grammes 
(150 grains) during the twenty-four hours; ordinarily 6 grammes a day will 
suffice. 

When once the pain is subdued, I take care not to stop the salicylate medi- 
cation, which, in smaller doses of two or three grammes a day is prolonged for 
a fortnight, but the dose is instantly increased if I see any tendency to a return 
of the rheumatism. For if the salicylic treatment often causes the symptoms of 
acute inflammatory rheumatism to disappear as if by magic, it does not arrest 
the disease altogether, and if you leave off abruptly the administration of the 
medicine, you will see the rheumatism return with a new intensity; the relapses 
are then more stubborn to treatment than was the incipient attack. Therefore, 
I cannot too strongly recommend you, after the cessation of pain, and the dis- 
appearance of the rheumatism, to keep your patients in bed for two weeks, and 
to consider them all this time as under the influence of the malady. 

Clinicians have much discussed and much exaggerated the dangers of these 
doses of salicylate of soda. Such disastrous results have been attributed to 
them, that you will sometimes see families obstinately oppose the employment 
of this medicament. The salicylate, in fact, does produce buzzing in the head 
and some vertigo, especially when the dose is large; but these symptoms are 
transient and not at all alarming. Children, it must be admitted, support 
admirably the salicylate, 1 while women experience the cerebral effects in a 
much more marked degree than men, and you should make a note of this fact 
when you prescribe it to females. 

1 Deseille, by observations made in the service of Bergeron, has shown that salicylate 
of soda is well borne by children, who can take six grammes a day with safety. Muscular 
rheumatism yields in forty-eight hours or more, and acute rheumatism of the joints experi- 
ences a very marked sedation at the end of two to five days of treatment, (a) 



{a) Deseille on the Salicylic Treatment of Rheumatism in Infants. These de Paris, 1879. 



ON THE TREATMENT OF ACUTE RHEUMATISM. 255 

To the salicylic medication have been attributed all the complications 
which may appear in the course of rheumatism, and in particular, those 
which manifest themselves on the part of the cerebrum, or the heart. This 
is a mistake. I believe, on the contrary, that the salicylate, administered at 
the onset of the rheumatism, opposes the evolution of the malady, and so 
far, within an actual limit, the cardiac complications which play so consider- 
able a part in the prognosis of rheumatism. Will the salicylic medication 
prevent every complication? Assuredly not, for in certain cases it is the 
cardiac rheumatism which appears as the first symptom of the disease. 

Therefore, you ought to employ this medication in the greater number 
of cases, and I know of but one contra-indication to the use of the remedy; 
namely: its non-elimination by the urine. This is a point to which I alluded 
when treating of diseases of the kidneys, in a former lecture. 

Whenever salicylate of soda is administered to a patient suffering from 
parenchymatous or interstitial nephritis, the smallest doses may determine 
cerebral accidents of the greatest gravity, therefore you ought to examine care- 
fully the urine of your patients before advising the salicylic treatment. 

Does salicylate of soda thus administered cure all cases of acute rheuma- 
tism ? One may reply in the affirmative for the great majority of cases. At 
the same time there are a certain number of rheumatic patients who are not 
benefited by this treatment. I am convinced, however, that save in exceptional 
cases, these refractory forms are tendinous rather than synovial, and that, as a 
general rule, the more frankly acute the rheumatism, the more amenable it is to 
medication by salicylate of soda. 

There is another form of rheumatism which resists the salicylate medica- 
tion. I refer to gonorrhceal rheumatism. Whether this rheumatic inflammation 
be diffused, or localized in a joint, it is pretty certain that salicjdate of soda has 
little or no action on these muscular or tendinous rheumatisms, and that you 
have no other means of subduing these obstinate arthrites but the revulsive 
method. 

Thus far I have been occupied only with acute articular rheumatism, but 
there are certain other forms of rheumatism of which I must speak. I refer to 
muscular rheumatism, and those rheumatisms which are not accompanied with 
fever, and which have been described under the name of rheumatic pains, pains 
which come on under the influence of atmospheric changes, and which are so 
frequent and so annoying in old persons of arthritic habit. These manifesta- 
tions are amenable to external treatment, and you can use revulsion or topical 
anodynes, or baths. 

Revulsion is one of the most powerful means of treatment of local rheuma- 
tism, and according to the degree of the arthritis, you can use tincture of 
iodine, 1 blisters and galvanic cauterizations. 



1 The officinal tincture of iodine (French Codex) is iodine I gramme, alcohol 12 
grammes. In the United States a decolorized tincture is prepared as follows : ]J Iodine, 5 
grammes; alcohol, 50 grammes; aquae ammon. fort., 11.60 grammes. M. It takes about 
five weeks to obtain complete decolorization. For relief of intense pain, the iodine tincture 



256 ON THE TREATMENT OF ACUTE RHEUMATISM. 

As for the iodine applications, you can make use of the tincture of iodine 
of the pharmacopoeia, or of the iodized cotton, 2 or if you desire still more revul- 
sive an action, you can add a little more iodine to your tincture. 8 

You can also make use of the means proposed by Bernard, 4 who based quite 
a therapeutic method on nascent iodine. This method consists in the decom- 
position, on the place where it is applied, of an alkaline iodate by tartaric acid. 
It is quite an efficacious way of procuring severe local revulsion. 

It is in these cases of rheumatic pains that use is made of the pomades and 
liniments of which I have before spoken. One point I must urge upon you: 
In these painful muscular and joint affections it is well to keep the limb at rest. 
Moreover, this immobilization is instinctively made by the patient, who thus 
seeks to avoid anything that will produce pain. CEhme has gone so far in this 
direction as to propose splints in the treatment of acute rheumatism of the 
joints. 5 I think that this is carrying immobilization to excess; and notwith- 
standing the importance which ought to be attached to arrest of movements 
in the treatment of certain mono-articular arthrites, it would be a mistake to 
apply retentive apparatuses in the case of inflammations so mobile and shifting 
in their character as are observed in acute rheumatism. 

Balneotherapy occupies an important place in the therapeutics of acute 
rheumatism, whether muscular or articular. This disease being generally pro- 
may be advantageously medicated with morphia as follows : ty Morphia, I gramme ; tinc- 
ture of iodine, 30 grammes. M. 

[A favorite anodyne application is the extract of belladonna or stramonium rubbed up 
into a paste with water, and spread on cloth, with which the affected joint is covered.] 

2 The iodized cotton is made according to Mehu's directions as follows : Take 25 
grammes (nearly an ounce) of finely carded stove dried cotton, sprinkle over it 2 grammes 
( 3 ss) of iodine reduced to powder, and heat to 100 degrees 212 F.) Eight per cent, of the 
iodine remains fixed to the cotton, (a) 

3 Bouvier gives the following formula for a stronger tincture of iodine than the officinal; 
5 Tinct. iodine, 30 grammes ; iodine 2.50 grammes ; iodide potas., 1.50 grammes. M. La- 
borde's tincture is still stronger: I£ Tinct. iod., 60 grammes; iodine, 10 grammes; iod. 
pot., 5 grammes. M. This solution has the consistence of paint, and is applied with a 
camel's hair pencil. (&) 

4 Bernard's solutions for nascent iodine are as follows: I^.- -Iodide of sodium, 98.85 
grammes; iodate of soda, 26.17 grammes; water, q. s. For a solution which will mark 12.5 
on the salinometer. This is No. 1. No. 2 is as follows: Tartaric acid, 125.80 grammes; 
water, q. s. To make a solution that shall mark 12.15 on the salinometer. Apply with two 
different brushes the two solutions successively, or surround the joint with cotton soaked in 
No. 1; the acid sweat will set free iodine by decomposition of the alkaline iodate. 

5 CEhme employs splints in the treatment of acute articular rheumatism, and he has 
compared the results obtained by this method in 45 cases of rheumatism, with 45 other cases 
treated by other methods. According to this writer, immobilization lowers the fever, and 
the total duration of the disease is diminished a week at least (c). 



(a) Delpech on Iodized Cotton. Bull. gen. de Th. t. 87. p. 33, 1874. 
(3) Laborde on The External Applications of Iodine. Bull, de Th , t. 87, p. 76, 1874 
(c) CEhme, Die behandlung des Rheumatismus acutus mit festen verbanden (Arch. derTheelkunde, 1875, 
5 th livr.) 



ON THE TREATMENT OF ACUTE RHEUMATISM. 257 

voked by the direct action of cold and dampness on the cutaneous surface, and 
by arrest of the functions of the skin, it has always been believed that sudorifics 
have a very energetic and beneficial action in the treatment of rheumatism, and 
that nature has given an indication for their employment in the abundant 
sweats that characterize the malady. Therefore it has seemed logical to increase 
the secretory action of the skin. Sudorifics have then been in fashion, whether 
administered internally in the form of ptisans or externally in the form of vapor 
baths; thus infusions of dulcamara (bitter-sweet) have been advised, of borage 
(borago officinalis), of bryony, and especially of the European ash (fraxinus 
excelsior) vaunted by Delarue, Marbotin and others. 1 I must not omit to 
mention the infusion of black cohosh (cimicifuga racemosa) so recently recom- 
mended by Bartlett. 2 

In the same group we must place jaborandi and pilocarpine, with which, in 
the treatment of rheumatic fever, Gubler, at the beginning of his career as a 
clinician, made several trials; trials which have seldom since been repeated. 

If diaphoretic infusions play a doubtful and disputed role in the thera- 
peutics of rheumatic fever, it is not so with external sudorific applications, such 
as vapor baths, the wet pack, 3 and hydrotherapy. 

Sudation is obtained by the vapor bath in two ways: either by the hot dry 

1 The leaves of the ash, fraxinus excelsior, have been much employed in rheumatism, 
and recently Delarue, Pouget and others have experimented with this old remedy, and have 
found the leaves efficacious as a therapeutic agent. The infusion, if we may judge by their 
trials, provokes abundant sweats and a copious diuresis. The leaves contain the medicinal 
principles, and the dry leaves are better than the green. With the former a decoction is 
made by infusing from half an ounce to an ounce in eight ounces of water, a pinch of pepper- 
mint leaves being added before steeping. This infusion is taken in teacupfuls every two or 
three hours; it may also be used in the form of lavements. The dried leaves may also be 
applied around the painful joints. Pouget has proposed a similar infusion, made by steeping 
fifteen grains of the dried powder of the leaves in about a gill of hot water; this is infused 
three hours and strained, (a) 

2 The black cohosh (also called macrotys) is much used in this country in acute and 
chronic rheumatism. It is a great favorite with eclectic practitioners. The decoction of the 
root (one' ounce to the pint) may be used in doses of one or two fluid ounces, or the tincture 
or fluid extract, in the dose of 15 drops every two hours, till relief is obtained from the pain 
and active diaphoresis is produced. According to some authorities its physiological action 
is characterized by slight nausea, vertigo and lowering of the pulse, but not by sweating. 
Dr. F. N. Johnson, of New York, was one of the first to introduce it in this country in the 
treatment of acute inflammatory rheumatism. It induced no sensible evacuations but dimin- 
ished the force and frequency of the pulse, and caused the pain to disappear. Dr. Simpson 
found it wonderfully efficacious in lumbago. In sciatica and rheumatic dysmenorrhcea it is 
highly vaunted. — Trans. 

3 Dowse employs in cases of acute rheumatism wrappings in wet sheets, and claims 
good results. He envelopes the patient in a sheet wrung out of warm water, which he 
covers with dry blankets, so as to provoke copious diaphoresis; from time to time the 
patient is made to drink some hot ptisan, (b) 



(a) Delarue, Jour, de Conn. Med. Chir., August, 1852. Pouget and Peyraud, Union Med., Dec. 9, 
Marbotin, Bull, de Ther., 1853. 

{b) Dowse, Brit. Med. Jour., 1875, pp. 39 and 106. 
§17 



258 ON THE TREATMENT OF ACUTE RHEUMATISM. 

air, or the hot moist air process, and we can in certain cases apply warm steam 
douches to the patient in bed, by projecting jets of steam around his body 
encircled with hoops which are covered by the bed clothes. 1 

During the last few years there have been great improvements in the pro- 
cesses of balneation. Zaba has advised the use of the vapor of water as hot as 
can be borne. Benoit, Bremond and others have added turpentine to these 
baths and have thus constituted terebinthinated vapor baths, which play an 
important part in the treatment of certain forms of rheumatism. By the side of 
these baths of medicated vapor, we place medicated baths, properly so-called, 
and among these last the sulphur baths. 2 These give good results in the treat - 

1 Vapor baths are divided into hot air baths (the hot air chamber) and vapor baths 
properly so-called. These baths are of great antiquity. The Egyptians employed dry air 
baths, also the ancient Mexicans, according to Von Humboldt. Among the Greeks and 
Romans these balneal practices were in great repute. After undressing in the spoliatorium, 
the bather entered the laconicum, an oven-like chamber filled with hot air, and in which pro- 
fuse perspiration was excited. Then he passed into the frigidarium, where he took a cool 
plunge bath, and from this he went on to the tepidarium, a warmer apartment where massage 
was practiced, and where he was dried and rubbed and anointed with oil. 

Hot air baths are given at the present day in special apartments which the subject 
enters, or they consist of partial air baths in which the head of the patient is protected from 
the heat. A simple way of administering this bath is to place the patient on a chair pierced 
with holes and covered with a cloth, beneath which an alcohol lamp is burning. He is then 
wrapped with blankets, all but the head. The temperature of the hot air chamber varies 
from 35 to 65 centigrade. It is not, however, prudent to exceed a temperature of 45° (113 
F). After staying a while in these hot air chambers, the subject takes an invigorating 
plunge in a cold tank, or receives a cold douche (as in the Russian bath). In the Turkish or 
Oriental bath, after emerging from the hot air room, the bather is shampooed, wrapped in 
warm towels and wiped dry. 

Vapor baths are also whole baths or partial baths. The temperature of these moist air 
chambers is lower than that of the dry rooms, and varies between 37 and 45 centigrade. 
At the same time the people of northern countries can support for a short time, without 
suffering, a temperature of 75 C. (167 F). 

[The partial vapor baths are given in a similar way to the partial hot air bath above 
described, a dish of hot water being placed over the alcohol lamp and made to evaporate; the 
vapor being confined by the bed clothes which envelope the patient, all but the head. In a 
very short time profuse perspiration takes place.] 

The last few years Fleming has studied the action of the Turkish bath. He has shown 
that it augments the temperature and pulse. The destiny of the urine is increased; it loses 
a great part of the chlorides, while the quantity of urea is augmented; arterial tension is 
raised. Fleming considers the Turkish bath a powerful curative agent in rheumatism, but it 
is contra-indicated where there is any heart affection, (a) 

Bremond's apparatus consists of a tight box in which the patient is confined, all but his 
head. Into this box steam is conveyed by a suitable generator; this steam carries with it 
minute quantities of the vapor of turpentine which impinges upon every portion of the body 
of the patient, except what is outside the box. Bremond affirms that by this means there is 
a considerable absorption of turpentine by the skin and elimination by the different emunc- 
tories. (b) 

2 There are several formulas for these sulphur baths. We present three : 



(a) Physiology of the Turkish Bath, Jour, of Anat. and Phys., July 13, 1879. 

(<$) Bremond, Cutaneous Absorption. A New Method of Treatment of Rheumatism, Paris, 1874. 






ON THE TREATMENT OF ACUTE RHEUMATISM. 259 

ment of rheumatic pains, but it is necessary to take great care, as Lasegue 
recommends, always to raise the temperature of the bath so that the bath will 
be hotter when the patient leaves it than when he enters it. 

It would now be in place to speak to you of the thermal treatment of 
rheumatism, but as this kind of treatment belongs rather to the chronic than to 
the acute manifestations of this affection, I will defer the exposition of this 
subject till my next lecture, when I will consider the treatment of chronic 
rheumatism and of gout. 

To sum up, then, what I have said : In simple acute articular rheumatism you 
need employ only one medication, the salicylate of soda, giving it from the very 
beginning in the doses of from four to six grammes ( 3 j to 3 jss) a day, and you 
must prolong the treatment a long time after the disappearance of the pain and 
febrile symptoms. In subacute rheumatism, whether articular or muscular, yet 
accompanied by severe pains and great mobility of symptoms, it is still well to 
make use of salicylate of soda. When, on the other hand, you have to do with 
vague rheumatic pains without fever — frictions, vapor baths and sulphur baths 
will serve you a good turn. In fine, when rheumatism localizes itself, it is the 
revulsive medication which you should employ, and according to the effects 
which you would produce, you may use successively tincture of iodine, vesica- 
toriesand punctiform cauterizations. It is this revulsive method which, joined 
to the use of suitable retentive apparatus, is of most efficacy in the treatment of 
gonorrheal rheumatism. It remains for me now to say a few words about the 
treatment of the complications of acute rheumatism. 

You all know the predominant tendency of rheumatism to affect serous 
membranes, and especially those of the heart. These endocardial, pericardial, 
pleuritic rheumatisms are all amenable to revulsive treatment, but you can 
prevent in a certain measure their development by the salicylic medication; and 
notwithstanding the statistics furnished by Fagge and Broadbent, I can assure 
you, after my own experience, that the salicylate of soda, administered from the 
very commencement of rheumatism, will oppose cardiac and pulmonary compli- 
cations. 3 Among these complications is one which is of great gravity, and 

i. Take of sulphide of sodium two ounces. 

Chloride of sodium two ounces. 

Dried carbonate of soda one ounce. 

Mix. To be added to the water of an ordinary full bath. 

2. Take of sulphide of calcium two ounces. 

Bicarb, soda two ounces. 

Chloride of sodium two ounces. 

Mix. For a bath. 

3. Take of tri-sulphide of potassium five ounces. 

Add to the water of an ordinary full bath. 

No. 3 is the most generally used. 

3 There is not perfect agreement among medical authorities respecting the influence of 
the salicylic medication as preventive treatment of the cardiac complications in rheumatism. 
In Germany certain statistics have been published which pertain to eighteen cases of acute 
rheumatism treated from the first or second day by the salicylate. In only five per cent, of 



260 ON THE TREATMENT OF ACUTE RHEUMATISM. 

which, by the treatment which it demands, has a place apart from the other 
manifestations of rheumatism. I refer to cerebral rheumatism. 

The accidents which may occur on the part of the brain in the course of 
rheumatism have multiple forms. 4 Sometimes intellectual troubles supervene, 
which my excellent friend Mesnet, my colleague in this hospital, has described 
under the name /<?//<? rheumatismale (rheumatic insanity). Sometimes veritable 
attacks of hemiplegia take place (rheumatic apoplexy) ; sometimes meningeal 
symptoms predominate; sometimes there exists hyper-pyrexia with or without 
delirium. This rheumatic hyper-pyrexia has especially attracted the attention 
of English physicians, and in his recent work on rheumatism, Maclagan de- 
votes a long chapter to this hyper-pyrexia, which he likens to that produced by 
sunstroke. He attributes it to irritation of the thermic nerves of the skin by 
lactic acid, the excess of which in the blood is, he thinks, the first cause of 
all the rheumatismal complications. It is this hyper-febrile movement which is 



these cases were there any cardiac lesions, instead of in eighty per cent., which has been 
given as the ratio of heart complications where this medicine was not used. 

English statistics give results completely opposite. The statistics furnished to the 
Medical Society of London in December, 1881, pertain to 5,000 cases. According to the 
statistics of Fagge, in 500 cases of rheumatism not treated with salicylic acid, there were 273 
with cardiac lesions, or fifty-four per cent. ; in 350 cases where various kinds of treatment 
were used, there were cardiac lesions in 227, or sixty- five per cent.; in 350 cases treated by 
salicylate there were cardiac lesions in 241, or sixty-eight per cent. According to the statis- 
tics of Broadbent, there were cardiac affections in fifty five per cent, where salicylates were 
not used; and in 1,748 cases in which ibis medication was employed, there were cardiac 
affections in 1,109, or sixty-three per cent. In England, then, instead of the small proportion 
of five per cent., we find a medium of sixty-four per cent, of cardiac complications during or 
following the salicylic medication. 

4 Hervez of Cnegoin was the first to describe, under the name of cerebral rheumatism, 
the brain complications which supervene in the course of rheumatism. These complications 
may be classed under four heads: Folie rheumatismale \ rheumatic apoplexy, rheumatic 
meningitis, and simple delirium with hyperpyrexia. 

Hyper-pyrexia is observed especially in connection with simple delirium, and it is this 
form which is benefited by cold baths. The delirium may even be wanting, and there exist 
rheumatisms with hyper-pyrexia, without delirious manifestations. Steward Lockie cites 
curious examples. The temperature rises in these cases to 41 C, and even attains a higher 
point. What characterizes this form of rheumatism is the disappearance of the articular 
phenomena, and their reappearance when the delirium is gone. Cerebral rheumatism has 
been accused of being provoked by the exhibition of certain medicaments, and in particular 
quinine. Aran has shown that these medicines have nothing to do with the production of 
cerebral rheumatism. The treatment of cerebral rheumatism by cold baths was first adopted 
by William Fox in 1871; then, the same year, by Moxon and Clifford Albutt; by Thompson 
and Russel in 1872; by Weber in 1873; by Raynaud in 1874; Fereol and Blachez in 1875, 
and Heubner in 1877. (a) 



(a) William Fox, On the Treatment of Hyperpyrexia as Illustrated in Articular Rheumatism, London, 1871 . 
Morton, Med. Timet, 1871, p. 243. Clifford-Albutt, Lancet 26 d^cembre, 1871. Thompson, Brit. Med. Journ., 
3 aug. 1872, et Med. Times, 19 mars 1873. Russel, Brit. Med. Journ., 20 mars 1872. Weber, A Case of 
Hyperpyrexia, Clin. Soc. Trans., V, 1872. Heubner, Zur Behandlung der Hyperpyrexia in Acuten Gelenk- 
rheumatismus des Sagenaunten cerebralrheumatismus, Arch, der Heilkunde, XVII, p. 134. 



ON THE TREATMENT OF ACUTE RHEUMATISM. 261 

of all the cerebral accidents of rheumatism, the only one amenable to treatment 
by cold baths. 1 

In the discussion which arose in 1875 in the sessions of the Societe des- 
Hopitaux, with reference to the treatment of cerebral rheumatism by cold baths, 
I was forced to take the ground that in the event of cerebral complications, 
the indication for this kind of treatment was derived neither from the disap- 
pearance of the joint symptoms, nor from the appearance of delirium, but from 
the elevation of temperature, and that the only guide in the use of cold 
baths was the temperature which in these cases may reach, and even exceed 
41 C. (nearly 106 F.) (b) 

This cold bath medication, recommended for the first time by William Fox 
in 187 1, and introduced into France by Maurice Raynard in 1874, has given, in 
certain cases, marvellous results. It consists in immersing the patient in cold 
water, according to the method of Brand, and in continuing or repeating the 
baths till the temperature is brought down, and remains below 40 C. (104 F). 2 

This kind of treatment is heroic, and you ought always to resort to it 
when you have to do with rheumatism complicated with excessive fever 

1 Maclagan dwells at great length on rheumatic hyperpyrexia. According to him there 
exists a special heat centre, situated probably in the upper part of the spinal cord, which 
governs and regulates the heat-production of the entire economy; this centre, which has 
the double power of producing and arresting heat, is in immediate connection with the 
thermic nerves which are abundantly distributed in the skin. It is thus that is explained 
the hyper- pyrexia produced by coup de soldi, and the febrile excesses observed in 
rheumatism. 

The skin possesses an extraordinary activity in rheumatic fever; the excess of lactic 
acid in the blood, which is, according to Maclagan, the point of departure of rheumatism, 
is the cause of the excessive sweats, and as this lactic acid is eliminated by the perspira- 
tion its elimination irritates the cutaneous surface. This irritation enlists the thermic 
nerves as well as those of common sensation, and through the thermic nerves the thermic 
centres are affected. As treatment Maclagan proposes cold applications. (a) 

2 Woillez has written a valuable monograph on the treatment of cerebral rheumatism 
by cold baths. According to him the indications of this bath are as follows: 

1. When to the delirium is joined diminution or disappearance of the articular flux- 
ion, and, moreover, a fever heat of 40° or more. 

2. When in cerebral rheumatism with the delirium there is no diminution in the joint 
symptoms, the fever heat being high. 

The Clinical Society of London has made some researches on this subject. These are 
their conclusions: 

1. The hyperpyrexia in acute rheumatism seems to prevail at certain epochs. Cases 
of this kind were very numerous between the years 1873-76. They have been more rare for 
the last few years. Without affirming that there exists a mathematical proportion between 
the number of cases of hyperpyrexia and of rheumatism, it may at the same time be ad- 
mitted that there exists a certain relation between them. The hyperpyrexia was more 
common in spring than in summer, while rheumatism is more frequent in fall and in 
winter. 

2. While the influence of sex on the frequency of rheumatism seems little marked, 



{a) Maclagan On Rheumatism, Its Nature and Treatment, London, 1882. 

0$) Dujardin-Beaumetz on The Indications of Treatment of Cerebral Rheumatism by Cold Baths. 
-(Union Med., 1875, and Bull, et Mem. de la Soc. Med. des Hop., Mars., 1885.) 



262 ON THE TREATMENT OF ACUTE RHEUMATISM. 

heat, one of the gravest of forms, and which speedily proves fatal unless 
you come to the rescue with active antipyretic treatment. 

I shall have finished, gentleman, the hints which I wished to give you 
in reference to the treatment of acute rheumatism, when I shall have set forth 
the dietetic and hygienic principles which should govern you in these cases. 
These general rules, save always the milk regimen counselled by Biot of Lyons, 8 
are much more applicable to chronic rheumatism and to gout. I will then defer 
them till my next lecture, when I shall speak of the treatment of these two 
affections. 

hyperthermia is more common in man than in woman, in the proportion of 1.8 to i„; the 
influence of age and professional occupation is nil. 

3. Hereditary predisposition to rheumatism is not a cause of hyper-thermia. 

4. Generally hyperthermia complicates the first attacks of rheumatism. 

5. It is not generally accompanied by accidents on the part of the viscera. The most 
common visceral complications are pericarditis and pneumonia. 

6. The mortality of acute rheumatism with hyperthermia is very high; hyperthermia 
is one of the principal causes of death in acute rheumatism. 

7. Sometimes, but not always, it is preceded by suppression of the joint pains and by 
perspiration. 

8. It is often preceded by delirium or other nervous accidents. 

9. The date of the appearance and the duration of the hyperthermia are very 
variable. 

10. Death, when it takes place, comes on generally on the second or third week of the 
rheumatism. 

11. It does not give place to the special lesions of the viscera; when there exist 
visceral lesions, these are not necessarily very extensive. 

12. The best treatment consists in making cold applications to the skin; these are the 
more efficacious, the earlier they are resorted to. The temperature ought not to exceed 
40.5° C. (105 F). If the baths do not suffice, one should have recourse to applications of 
ice, to cold lotions, to the wet pack, to injections of ice water, etc. {a) 

3 Biot, of Lyons, employs the milk diet in rheumatism. According to him, this regime 
alleviates the pain and lowers the thermic curve. This effect is largely due to the activity 
given to the renal functions, {b) 



{a) Woillez, Du rhumatisme cerebral et de son traitement par les bains froids (Bui. gen de The>., p. 334 
et 397, October et November, i38o). Report concerning hyperpyrexia in acute rheumatism, by a Commission 
of the Clinical Society of London (Med. Times and Gaz., June 3, 1882). 

(b) Biot, On Milk Treatment of Acute Rheumatism. Revue Mens.de Mfcd . et Chir. Mars, Avril P 
Mai, 1879 



ON THE TREATMENT OF CHRONIC RHEUMATISM 

AND GOUT. 

Summary: — Chronic Rheumatism — Origin of Gout and Chronic Rheumatism — Arthritism — 
Arthritis Deformans — Treatment of Arthritis Deformans — Internal Medication — Arse- 
nic — Iodine and Iodides — Salicylate of Soda — External Treatment — Electricity and 
Massage — Thermal Treatment — Dietetic Treatment — Action of Cold — Gout — Pathogeny 
of Gout — The Uric Acid Diethesis — Etiology of the Uric Diathesis — Therapeutics of 
Gout— Treatment of the Fit of Gout— The Fit of Gout— Ought We to Treat the Fit of 
Gout — Visceral Complications of Gout — The Gouty Kidney — Bloodletting — Sudorifics 
— Guaiacum — Purgatives — Specific Treatment of Gout — Sulphate of Quinine — Colchi- 
cum — Preparations of Colchicum — Vegetal Treatment of Gout — Alkalies — Salicylate 
of Soda — External Treatment of the Fit of Gout — Resume of the Treatment of the Fit 
of Gout — Treatment During the Interval — Alkalies — Lithia — Bitters and Tonics — Ther- 
mal Treatment — Hygienic Treatment. 

Gentlemen: — I propose in this lecture to consider the treatment of chronic 
rheumatism and gout. By these words, chronic rheumatism, I do not mean all 
chronic forms of rheumatism, but rather that variety which affects the bones, 
and which is characterized by those deformities of the small joints which have 
given to this affection the name of nodular rheumatism or arthritis deformans? 

Confounded from remote antiquity under the name of arthritism, gout and 
chronic rheumatism have been now grouped in the same description, now con- 
stituted as distinct entities, according as writers have taken for their basis the 
etiology, the symptomatology, or the pathological anatomy of these two affec- 
tions. To-day this question, after many vicissitudes, seems to have reverted to 
the point from which it started, and if we observe between gout and rheumatism 
differences radical and complete, we recognize also that they may derive their 
origin from one common hereditary source. 

1 Charcot has referred chronic articular rheumatism to three principal types: i. Chronic, 
primitive, articular rheumatism, generalized or progressive; this is the nodose or deforming 
rheumatism of authors, a rheumatism remarkable especially for its tendency to become gen- 
eral, by beginning in the little joints and particularly those of the hands, by the deformities 
and disorders which it occasions. 

2. Chronic, primitive articular rheumatism, fixed and partial. This is the dry arthritis 
of surgeons; it generally affects only one joint, preferably that of the hip {morbus coxce seni- 
lis). 

3. Heberden's nodosities (digiiorum nodi) which occupy the joints of the phalanges and 
palangettes, while sparing the matacarpo phalangeal articulations. Besnier has divided the 
forms of chronic articular rheumatism into three groups: 

Simple chronic rheumatism, chronic fibrous rheumatism, chronic bony rheumatism. 
The latter is subdivided into three groups: Chronic multi-articular bony rheumatism; chronic 
partial bony rheumatism; chronic rheumatism of the phalanges, (a) 



(a) Charcot, Lecons sur le rhumatisme chronique, recueillies par Ball. Besnier, Art. Rhumatisme, in 
JDictionn. encyc. des sciences m<2d. 

263 



264 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

To this hereditary cause of these two diseases we give the name of arthrit- 
ism, and if gout and rheumatism have at their origin many points of contact, 
they soon separate in two divergent directions, of which the two extremes are 
chronic arthritis deformans, on the one hand, and acute gout on the other. 
This opinion, which I defended at the time of the discussion which arose in the 
Society of Hydrology, between the partisans of arthritism and those who, like 
Durand Fardel, persist in seeing in gout, chronic rheumatism, and acute rheu- 
matism, distinct morbid entities, I maintain to-day, for when you carefully trace 
back the genealogy of arthritic patients, you almost always find rheumatism in 
all its forms, or gout in all its modalities. At the same time, take note that 
quite recently our colleague Lancereaux has withdrawn arthritis deformans and 
dry arthritis from the category of arthritism to place this affection in the group 
of herpetic disorders. But this is a new view which needs to be discussed before 
being adopted. 

Scarcely recognized at the beginning of this century, 1 chronic rheumatism 
with articular deformity, which is described under the name of nodular rheu?na- 
tism, has not been well understood till within a few years, and it is especially to 
the School of Salpetriere and its eminent master, Prof. Charcot, that we are 
indebted for the exposition, both from the standpoint of symptomatology 
and pathological anatomy, of the palpable and striking differences between 
gout and arthritis deformans, to the latter of which even now some authorities 
persist in giving the name of gouty rheumatism. 

Even if we well understood the lesions of chronic rheumatism (arthritis 
deformans), the pathogeny and the course of the affection, 2 it must be confessed 
that the therapeutics of this disease has made little progress, and our efforts 
remain well-nigh impotent to arrest the progressive and invading march of those 

1 The description of chronic deforming rheumatism is of recent date, and the first writ- 
ing respecting it goes back to the beginning of this century. It was Landre-Bauvais, interne 
under Pinel, who, in his inaugural thesis in 1800, was the first to call attention to this form 
of rheumatism under the name of primitive asthenic gout. Heberden in 1804 discribed the 
nodosities of the joints in rheumatism; Haygarth in 1805 reviewed and completed this 
description. Lobstein, in 1833, described in his treatise of pathological anatomy the eburn- 
ated state of the bones; Deville, in 1845, called the attention of the Anatomical Society to 
the alterations of chronic rheumatism; finally, Charcot, in 1853, completed this description 
and established the anatomical and clinical distinction which separates gout from rheu- 
matism.' (a) 

2 The patho-anatomical lesions of chronic rheumatism affect the constituent parts of 
the joint : synovial membrane, diarthrodial cartilages, bones, and ligaments. 

The synovial membrane at first slightly injected, and of pinkish color, soon becomes 
thickened, intensely red, and is traversed by numerous blood-vessels, varicose, more or less 
dilated, and surrounding the borders of the diarthrodial cartilages like a collar ; it presents 
a roughened appearance and is covered with little prominences of variable size, from 
a millet-seed to a bean ; these little bodies constituted by young connective tissue cells, and 
sometimes also by cartilage corpuscles, ai-e pale or rosy in hue, and resistant to the finger ; 



O) Vidal, Considerations sur la rhumatisme articulaire chronique primitif (These de Paris, 1853). Char- 
cot, Lecons de la Salpetriere, recueillies par Ball. Lobstein, Traite d'anatomie pathologique, t. n, p. 207. 
Landre-Bauvais, Doit on admittre une nouvelle espece de goutte sous le nom de goutte asthenique primitive ? 
(These de Paris, 1800.) 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 265 

lesions which eventually constitute incurable infirmities, and condemn the un- 
happy patient to a life of invalidism. 

The treatment of chronic rheumatism comprises external and internal 
means. The internal treatment comprehends but few medicaments ; those 
most in use are arsenic and arsenical preparations, iodine and the iodides, and 
salicylate of soda. Arsenic is given internally, as Charcot recommends, or 
employed in the form of arsenical baths (which have been especially vaunted 
by Noel Gueneau de Mussy) ; this treatment, whether it consists in the internal 
administration of arsenic or in the use of the baths, often provokes a return of 
the painful crises; hence this medicament should not be resorted to when there 
are any acute symptoms. 3 

the vascularization of the synovial fringes may give to the membrane a fleecy and fungous 
aspect. 

The foreign bodies which are met with in the joint are sometimes free, sometimes 
pedunclated, sometimes sessile ; they are constituted either of masses of fatty or connective 
tissue or of cartilaginous or bony substance ; according to their age they are more or less 
large, more or less soft ; when the transformation into bone takes place they become hard, 
resistant and opaque. 

The synovial liquid is wanting or exists in very small amount and contains blood glob- 
ules, epithelial or cartilage cells. 

The cartilages lose their bright, smooth, lustrous appearance. Their surface is irregu- 
lar, with velvety aspect and presents here and there ulcerations of greater or less depth. 
Here there are erosions, superficial, elliptical, or ovoid, as if lightly scooped out; in other 
places there are veritable losses of substance with complete disappearance of the cartilage to 
a greater or less extent, and this especially in places where the articulating surfaces are 
subject to much friction. On the margin of the articular cartilage you observe, on the other 
hand, a multiplication of the cellular elements contained in the cartilaginous capsules ; 
numerous enchondroses are formed which unite in the form of crowns and by their ultimate 
transformation give place to a zone of osseous tissue over the entire circumference of the 
diarthrodial cartilage. 

The extremities of the bones entering with the composition of the joint are swollen and 
covered at the margin with osteophyte productions, disseminated, or united and forming a 
sort of crown at the surface of articulation. 

In the points where the cartilage has disappeared, the bone is more compact, it is an 
eburnated substance, formed of a layer of osseous lamellae in which one fails to find Haver- 
sian canals ; the surface is white and smooth, sometimes furrowed with grooves, due to 
friction of the two articulating surfaces. 

Below the eburnated layer, the medullary spaces are, according to Vergely, filled with 
a great number of medulloceles and blood-vessels, while still deeper the spaces are enlarged, 
deprived of medulloceles, and filled with fat, and the osseous trabeculae are diminished or 
reduced to the state of tenuous filaments, whence results the friability of the tissue of the 
epiphyses, which may be perforated by the scalpel or broken down under the finger. 

The ligaments undergo variable modifications ; sometimes there is nothing appreciable 
to the sight, at other times they are indurated or shortened, thinned, atrophied, and even 
occasionally encrusted with calcareous salts. 

The tendons may undergo the same modifications ; greater thickness, less resistance, 
atrophy or even disappearance. 

The muscles which are in the vicinity of the articulation often present atrophy, thinning 
and decolorization , they are infiltrated with fat, and even at times undergo fibrous degener- 
ation, with or without the bony transformation. 

3 Gueneau de Mussy has recommended two kinds of arsenical baths ; the arsenical 



266 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 



However different these two modes of exhibiting arsenic may be, their 
principle of action is essentially the same, namely, by absorption of the medica- 
ment and its penetration into the economy, the rate of whose nutrition is 
raised. It must be confessed, however, that cutaneous absorption from baths is 
infinitesimal or nil. 

Iodine has been employed in chronic rheumatism by Lasegue. He made 
use of the tincture, of which he was in the habit of giving large doses, as much 
as a drachm and a half a day (six grammes). It is given diluted in water, or, 
what is better still, in a little old Spanish wine, which constitutes a mixture 
which is but slightly disagreeable and is easily taken with the meals. Instead 
of iodine, iodide of potassium may be given. Besnier proposes to give the 
iodide in syrup of coffee, which he thinks is the best adjuvant, and from one to 
three grammes a day (15 to 45 grains) may be given in this way. Iodine and 
the iodides in these cases act especially by stimulating the organism and 
energizing nutrition. These are the most important indications to fulfil in the 
treatment of chronic rheumatism, and Garrod has justly insisted on this point 
in showing us that the dominant fact of the treatment ought to be to fortify the 
system and to excite the nutritive activity, which is considerably lessened ; con- 
sequently, he recommended ferruginous preparations, cinchona bark, and, 
above all, cod liver oil. 

These indications are quite different from those which are applicable to the 
treatment of simple gout, and which should make us altogether discard in the 
treatment of chronic rheumatism the alkalies, which are heroic medicines in the 
gouty diathesis. This proscription of alkaline preparations ought not to include 
salicylate of soda. Whatever See may have said, who has affirmed that salicylate 
of soda may cure chronic rheumatism, I have never obtained the same effects 
from it. Nevertheless, while recognizing that if it is impotent in combating 
chronic rheumatism with joint deformities, the salicylate may be employed to 
advantage in the acute exacerbations which attend this disease ; it diminishes 
then both the acuteness of the pain and the intensity of the -febrile manifesta- 
tions. 

The interna] treatment, then, of chronic rheumatism, may be summed up 
in a few words : arsenic in appropriate cases, iodide in others, and salicylate of 
soda in the periods of exacerbation. 

The external treatment is much more complex. It comprises, first, all the 
local means which I enumerated a propos of acute rheumatism, as well as most 



bath pure, which contains from fifteen grains to two drachms of arseniate of soda per bath, 
and the compound arsenical bath, which with the same quantity of arseniate of soda has 
from three to five ounces of carbonate of soda. Apropos of the application of these baths, 
Gueneau de Mussy distinguishes two forms of rheumatism : chronic rheumatism with little 
pain, and rheumatism with subacute attacks. In the first kind he would employ the com- 
pound arsenical bath, in the second the bath containing only the arsenical salt. The tem- 
perature of the bath varies from 86° to 95 ° F. (30 to 35 ° C.) ; as for its duration that 
depends on the degree of excitability of the patient, (a) 






(a) Gueneau de Mussy. Clin. Med., t. i. p. 271, Paris, 1874. 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 26V 

of the artificial baths which I have described ; but to these means we must join 
others which have a very marked action in chronic rheumatism, in the first rank 
of which we place electricity. Whether the rheumatism has exerted its action 
primitively on the muscular tendons, or whether it has affected first the bony or 
fibrous parts of the articulation, it seems to be demonstrated that the deformities 
of chronic rheumatism, which are so numerous, depend on the retraction of cer- 
tain muscular groups. There are even cases in which rheumatism very speedily 
causes atrophy of the muscles, producing in this way considerable loss of power 
in the limbs, and without any apparent deformity. 

It is easy to understand the utility of electro-therapeutics in such cases. 
If you employ this agent, you must use galvanic currents, which have an influ- 
ence on nutrition in general, and that of the muscles in particular. Erb, Remak, 
Onimus, Jules Cheron, etc., have long insisted on the remarkable action of these 
currents in causing the articular deformities gradually to disappear, and, for my 
part, I have obtained successful results of this kind which are really marvellous. 1 
You should then always have recourse to constant currents when the pheno- 
mena of muscular irritation have disappeared. If you resort to this powerful 
therapeutic agent in time, you will be able to restore movement, and the use of 
the affected joints, and to attain this you should, as Dally has recommended, 
associate massage with the employment of electricity. To these powerful 
means of treatment in chronic rheumatism, the methodical employ of mineral 
waters should be added. 2 

1 These are the conclusions of Remak, respecting the applications of constant currents 
to the treatment of chronic rheumatism. 

Electrotherapeutics has for its object : 

ist. To provoke catalysis in the interior of the tendinous part of the joint which is 
affected with inflammation, exudation, or sclerosis. 

2d. To excite or accelerate a flux of liquid by impressions made on the blood-vessels 
distributed to the joint. 

3d. To remove the muscular inflammation which often complicates the arthritis. 

4th. To relieve the secondary contractures of the muscles, contractures which are kept 
up by the pain and inflammatory irritation. 

5th. To remedy the paralytic and atrophic states which affect all the muscles as a result 
of inflammation, inactive or impeded circulation. 

Onimus maintains that in the joint pains, galvanism is of indisputable utility, and 
ought to be tried even when the disease seems to be incurable, (a) 

2 [Walton (Mineral Springs of the United States and Canada) very properly divides 
rheumatics into two classes, those of the lymphatic temperament, and those of the nervous. 
In the former, waters rich in the sulphurets have seemed to produce the best results, and 
baths of a high temperature are indicated ; in the nervous temperament, however, waters 
containing but a small proportion of these constituents and of moderate heat, like the Vir- 
ginia Hot Springs, are preferable. The hot sulphur springs have been much recommended 
in the treatment of chronic deforming rheumatism ; these benefit more by their elevated 
temperature than by any saline or sulphurous constituents. We have a great variety of 
such springs in this country. We may instance the so-called Hot Springs, in Garland 
County, Arkansas, whose waters resemble those of Gastein, in Austria, and Pfaffers, in 



(a) Remak, Galvanoth^rapie, trad, de Morpain, i860. — Onimus et Legros Traits d'electricit^ mddicale, 
Paris, 1872, p. 45. 



268 ON THE TREATMENT OF CHRONIC RHEUMATISiM AND GOUT. 

Mineral waters play a considerable part in the treatment of rheumatism, and 
Aix in Savoy, and Plombieres, Naris, Luxeuil, Dax, Chattauneuf, Chaudes-Aigues, 
Bains dans les Vosges, Bourbonne-les-Bains, and Bourbon-l'Archambault, and 
many others not to mention any out of France, have been counselled in rheuma- 
tism. There is a great variety of these mineral waters. It may in fact be said 
in a general way that all the thermal waters of high temperature are useful in 
the chronic forms of rheumatism. Three stations have especially been recom- 
mended : Plombieres, Aix in Savoy, and Dax. 

To Plombieres you should direct your lymphatic and anaemic rheumatics, 
and those who are affected with visceral troubles of arthritic nature. To Aix- 
le-Bains where massage is practiced in a marvellous manner, you should 
recommend patients of a plethoric and congestive type. Lastly to Dax, where 
mineral mud baths are employed, you should send your chronic rheumatic pa- 
tients ; moreover, these spas present the great advantage that they constitute 
rather a winter than a summer station. 

To these waters you should join the ferruginous springs, as Garrod 
recommends ; such are those of Spa, of Schwalbach, of Mauritz, etc., the tonic 
action of which gives good results in rheumatism. 

The necessity of tonic treatment should influence you in advising the dietary 
of these rheumatic patients, and all your efforts should be directed towards 
augmenting their nutrition. You should order a substantial nourishment such 
as red meats, generous wines, for, contrary to what takes place in gout, the uric 
acid diathesis does not exist in chronic deforming rheumatism. Urge the need 
of out-door air and exercise, to combat the muscular atrophy of the members. 
You should especially insist upon the necessity of avoiding damp cold. The 
impression of cold is one of the most active causes in the production of rheu- 
matism, whether it acts directly on the nervous system, as Heyman 3 thinks, or 
in modifying the functions of the skin, permitting, as Hueter and Klebs believe, 
the introduction of organized phlogistic agents in the blood. This effect of cold 
is admitted by all observers, and is especially seen at periods of life when the 
body is most likely to be exposed to sudden changes of temperature; you must 



Switzerland ; the Calistoga Hot Springs in* Napa County, California ; the California Gey- 
sers ; the Santa Barbara Hot Sulphur Springs in California ; the Middle Park Hot Sulphur 
Springs in Colorado ; the " Warm Springs," in Madison County, North Carolina ; springs of 
the same name in Meriwether County, Georgia ; the Lebanon Springs in Columbia County, 
New York ; the Hot Springs of Bath County, Virginia ; and, lastly, the Salt Lake Hot 
Springs in Utah. The hot springs of Virginia and Arkansas are very fashionable places of 
resort ; to the treatment by baths are conjoined massage and douches.] 

3 Heyman has studied the influence of cold in the production of rheumatism. He main- 
tains that it is by the medium of the nervous system that cold causes rheumatism. Accord- 
ing to his view, the action of dry or damp cold on the skin impresses the nervous centres, 
and these, by reflex irritation of the trophic nerves, determine various troubles at the point 
where the cold acts, or in other parts of the economy, (a) 



(a) Heyman, Ein, beitrage zur rhumatische lehre (Arch, fur path, aiiat. and phys., t. vi, 3e livraison). 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 269 

then avoid these variations of temperature, 1 and their results, which often de- 
pend on the rapid evaporation of perspiration, by making your patients wear 
flannel and shun exposure to the winds, and particular to the west wind. 2 

You should have a surveillance also of the dwellings of your patients, pro- 
viding as far as possible that the conditions of the habitation shall be of a sani- 
tary kind, with apartments airy and free from moisture and the moulds which 
moisture generates, — cryptogamic productions which Moses in Leviticus char- 
acterizes as the plague in the walls of the houses 3 (Leviticus, 14, 36, etc.). 
Therefore, whenever your patients are well enough off to afford it, you should 
insist upon their avoiding the autumn rains, by going early to the winter stations. 
In a word, do not' forget, gentlemen, that rheumatic arthritis, which has been 
called "poor man's gout," affects only those individuals whose nutrition is im- 
poverished and enfeebled, and that all your efforts should be directed toward 
restoring the forces of the organism and stimulating the nutritive exchanges. 
This it is that explains how the treatment by arsenic and the iodide of potassium, 
the tonic medication under all its forms, is of use in these cases without being 
able always absolutely to oppose the invading march of the disease, which is 
generally fatal in the end. 

Gout presents quite different indications of treatment, and the adage that 
to contrary affections contrary remedies are indicated, is especially applic- 
able to these two diseases, gout and chronic rheumatism, which, born of a 
common parent, are distinct diseases from a clinical as well as from a thera- 
peutical standpoint. While we can observe at our hospital chronic rheuma- 
tism under all its forms (and grave cases are not wanting), we seldom or 
never meet with gout; or at least but one kind of gout is common in our wards, 

1 In making a summary of the statistics of the hospitals of Paris during the years 1868, 
1869, 1872, and 1873, Besnier has shown that acute articular rheumatism, with respect to the 
frequency of its occurrence, is not influenced by the regular order of the seasons except in a 
very limited proportion; it is, nevertheless, in the spring that more cases are observed. in 
Paris, (a) 

2 Peters has studied the influence of climates on the production of rheumatism. Accord- 
ing to this writer, in chronic rheumatism the aggravations coincide with a considerable fall 
in the mean temperature from one day to another, with a very moist atmosphere, a preval- 
ence of west winds, and a large proportion of ozone in the atmosphere, (b) 

3 Charcot has dwelt at great length on the action of damp tenements in the production 
of rheumatism: "A dwelling on the ground floor, dark, damp rooms, wet garments, paper 
peeling from the walls — this is the condition in which we find the homes of most of those 
who are attacked with chronic rheumatism, and besides the patients have lived a long time 
in these sorry surroundings — for four, six, eight and ten years." 

Gueneau de-Mussy also,has pointed out the unwholesomeness of the walls of tenements, 
characterized as they often are, by the presence of cryptogamic growths or moulds which 
Moses has described in Leviticus under the name of the "plague of the houses." These 
cryptogamic growths may possibly have an influence on the development of rheumatism, (c) 



O) Besnier, Art. Rhumatisme, in Diet. Encyc. des. Sc. Med. 

{b) Peters, in Berlin, Klin. Wochens. nos. i and 3, p. 15 and 33. Jan'y. 13 and 20, 1879. 
{c) Charcot on "The Diseases of Old Age." Wood's Library Series, 1881, p. 151. Gueneau de-Mussy, 
Clinique Medicale, Paris, 1874, t. 1, p. 305. 



270 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

that from lead-poisoning, 1 and I have already shown you, in my service, 
curious examples of this affection, whose description we owe to Charcot, Garrod, 
Ollivier and Lancereaux. But in your private practice it will not be so, and 
you will there meet with a considerable number of gouty patients, although 
their number tends to become less every day. This diminution results chiefly 
from the fact that the number of idle men tends also to decrease and that the 
struggle for existence demands of almost everybody a certain amount of daily 
labor. 

Without entering here into the details of the different theories that have 
been put forth as to the pathogeny of gout, it may be said that the humoral 
theory of the disease has always counted the most adherents. According to 
Sydenham, gout is the result of a peccant humor, a morbific matter, which 
nature endeavors to get rid of. Substitute for these words peccant humor, 
morbific matter, uric acid and urate of soda, and you will have the theory to-day 
admitted by physicians generally; and notwithstanding the reserves recently 
formulated by Bouchard, it seems to be proved that every attack of gout is due 
to excess of urate of soda. 2 But is is not sufficient to know that this excess 



1 Falconer in a work on the waters of Bath says that the colica pictonum is often ac- 
companied with gout. Hillier-Parry in his medical work has a long chapter entitled " Gout 
from Lead." Garrod affirms with great positiveness the existence of this form of gout. 
Charcot, Ollivier, and Lancereaux also point out the frequency of saturnine gout. 

Lead gout is accompanied, like ordinary gout, by the uric acid diathesis, and this dia- 
thesis results from the interstitial nephritis which is common to persons suffering from 
lead poisoning, and which hinders the elimination of uric acid, (a) 

2 The nature of gout has given rise to several theories which may be ranged in 
two groups: in the one has been considered the action of the solids as the starting point 
of the disease, in the other an alteration of the humors has been invoked in explanation. 

The "solidists" have enumerated three orders of primordial causes of gout: stomach 
troubles, disturbances of the nervous system and of the joint elements. 

Boerhaave and Van Swieten located the cause of gout in the stomach; whence the 
celebrated aphorism of Boerhaave "Ejus vitii origo proxima in indigestione viscerum." 

Cullen is the principal defender of the nervous doctrine, according to which gout is a 
disease of the entire economy, but in particular of the nervous system. Like Boerhaave, 
he assigns an important part to the stomach. This doctrine has been revived by Braun 
who maintains that the fit of gout consists in a primitive and idiopathic alteration of the 
peripheral nerves, and that we ought to range it in the group of neuroses. 

As for the writers who have assigned to joint troubles the origin of gout, we must 
mention in the first place, Hoffmann and Musgrave; the first has attributed the gouty 
paroxysm to violent spasm lacerating the fibrous ligaments of the joint. This spasm is 
produced by a depraved and acrid serosity, furnished by the little arterioles and glands of 
the ligaments. Musgrave makes gout consist in a disease of the minute follicles situated 
around the articulation and in the articulation itself. According to him gout, like scrofula is an 
alteration of the glands. 

Alard and Ficinus refer the cause of gout to alterations of the joint lymphatics. 



{a) Falconer, Essaisur les eaux de Bath, 1872. — Musgrave, De arthritide symptomatica (Genovae, 1752, 
cap. x, art. 5, p. 65). — Hillier-Parry, Collections of the unpublished medical writings of the late C. Parry \ 
London, 1855, p. 243.— Garrod, Medico-Chirurg. Trans., vol. XXXVII., 1854. — Charcot, Soc. de biol., 1871. — 
Ollivier, These de Paris, 1863, et Arch. Gen. de med. y t. II, p. 430 et 709.— Lancereaux, Soc. de biol., 1870; 
Unionmed.y 15 D^cembre, 1863, p. 513. 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 271 

of uric acid is the first cause of gout, we need chiefly to know the reason of this 
accumulation. 

Since the time when, in 1793, ninety years ago, Forbes Murray affirmed 
the starting-point of gouty symptoms to be the presence of uric acid in the 
humors of the economy, many hypotheses have been advanced to explain the 
first cause of this uric diathesis. Residuum of the imperfect combustion 3 of 
albuminous matters, cinders, as it were, of the economy, uric acid is the 
result of the incomplete nutritive operations of the human system. Urea, 
which is a more perfect product of organic combustion, has an origin which 
varies according to the ideas advanced as to its production; thus it is that 
Provost and Dumas regard this substance as the result of an oxidizing process 

The group of humorists is far the more numerous. Sydenham was one of the most il- 
lustrious representatives of this doctrine; in his estimation gout depends on a morbific 
matter produced by imperfect coctions, and the symptoms of gout are an expression of 
the efforts of nature to expel this peccant matter. 

In 1797, Wollaston and Tenon proved that the concretions of gout are composed of 
urate of soda, and for the peccant matter of Sydenham was substituted the uric acid 
diathesis, and it is Garrod who has given this theory its greatest completeness. Accord- 
ing to him, uric acid in gout, under the form of urate of soda, exists always in abnormal 
proportion in the blood, and this is a necessary condition to the production of the parox. 
ysms which are characterized by the presence in the interior of the joint of crystalline 
deposits of the urate. 

This doctrine, supported by Charcot, has been combatted by Bouchard who affirms 
that there is not always in gouty persons an excess of uric acid in the blood. He believes 
gout to be a disease characterized essentially by retardation of nutrition, (a) 

3 Uric acid (C 5 H 4 N 4 3 ) is a product of the oxidation of urea. Submitted to the 
action of oxidizing agents it furnishes three series of bodies, alloxane ,(C 4 H 2 N s 4 ), para- 
banic acid (C 3 H 2 N 3 3 ), and allantoid, (C 4 H 6 N0 3 ). 

Uric acid by oxidation and hydration breaks up into urea and alloxane. 

Urea is the ultimate term of the azotized matters of the economy. Bechamp and 
Ritter have obtained urea directly by oxidizing albuminoid matters with permanganate of 
potash. 

There has long been earnest discussion concerning the origin in the organism of urea 
and uric acid; some authorities have maintained that urea is formed in th» kidneys. 
This opinion has been combated by Prevost, Dumas, and Grehant, who have disproved it 
by showing the accumulation of urea and uric acid in the blood of animals in which the 
kidneys had been extirpated. Dumas has maintained that it is in the ultimate capillaries 
that the oxygen of the arterial blood destroys the tissues which have become unfitted for 
life, and Hirtz calls urea the ashes of animal combustion. 

Bouchardat and Robin think that urea and uric acid result from the process of dis- 



(a) Sydenham, De podagra et hydrope, London, 1683. — Musgrave, De arthritide symptomatica disserta- 
tio, 1707. — Hoffmann, De doloro podagrico, 1701. — Garrod, the Nature and treatment 0/ gout, and rhumatic 
gout, London, trad, par Ollivier et annote par Charcot, Paris, 1869. — Charcot, Etudes pour servir a Phistoirede 
r affection deer it e sous le nom de goutte asthenique primitive, nodosite des jointures (these inaugurate, Paris, 
1853. — Sur les concretions tophacees de V oreille externe chez les gouteux (Gaz. hebd., i860). V intoxicat ion 
saturnine exerce-t-elle une injlztence sua le developement de la goutte {Gaz. heb., i86$).—Lecons sur la goutte 
{Gaz. des hop., 1866). — Lecons sur la goutte {Gaz. des hop., 1867; Bull, de therap., 1867). — Legons sur les maladies 
des viellards el des maladies chroniques, recuellies par B. Ball, 1867. — Baaun, Deutsche Klinik, 1854, p. 22; 
Beitrage qu einer monographe de Gicht, Wiesbaden, i860, trad, par Meder, Paris, 1862. — Bouchard, Maladies 
par ralentissement de la nutrition, Paris, 1882, p. 264. — Paul Pouzet, Contribution d I etude de la goutte (these 
de Paris, 1878). 



2*72 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

in the capillaries, while Robin and Bouchardat consider it as a product of dis- 
assimilation, and, on the other hand, Brouardel, Charcot, and Murchison, think 
that the liver chiefly is concerned in its elaboration. 

Whatever theory one may adopt, the main fact that you should bear in 
mind, is that there will be increase or diminution in the production of uric 
acid according as nutrition is perfect or imperfect. As for the accumulation 
of urea and uric acid, it may result from two causes which shed light on 
the pathogeny of gout. In the one case the uric diathesis has for its origin 
excess of production; in the other, the production remains the same, but there 
are troubles in the function of the kidneys which prevent the elimination of 
uric acid, and it is these two great factors which we shall have to study when 
we examine the prophylactic treatment of gout. 

The medicines recommended for gout are very numerous; their number 
was considerable in the time of Lucian, if we may judge by his dialogue on 
gout. 4 

similation in the economy. Finally within a short time, Brouardel has claimed that the 
production of urea or uric acid is limited to a single organ, the liver, and Murchison and 
Charcot have adopted this view, a view on which Murchison has even based a new theory 
of gout. 

The congestion of the liver is the central point of gout; this congestion occasions 
an augmentation of the secretion of uric acid which is the point of departure of a condition 
of uricaemia; the latter inducing, by the passage of urine too much charged with uric acid a 
granular nephritis which in its turn opposes the elimination of uric acid, (a) 

4 " What mortal knows not me, unconquered gout, 
Great queen of pain, whom not the reeking blood 
Of many victims on the altars slain, 
Nor richest incense, nor the votive gifts, 
O'er the proud temples hung can e'er assuage, 
Nor mighty Paean's self, with all his herbs 
Medicinal, nor Phcebus's skillful son, 
Great ^Esculapius, can subdue: since man 
Was first created, hath he rashly strove, 
But strove in vain, with every fruitless art 
To check my conquests and elude my power. 
Whilst some their plantane and their smallage bring, 
Lettuce or purslane, hore-hound, nettles sharp, 
•Fen-gathered lentiles, or the Persian weed, 
Leeks, scallions, poppies, henbane or the rind 
Of ripe pomgranate, frankincense and fleawort, 
The root of potent hellebore or nitre; 
Some steeped in wine, the husks of beans prescribe, 
Or spawn of frogs, a sovereign cataplasm, 
Carrot, or pimpernel, or barley flour, 
Or gall of cypress tree, the healing dung 
Of mountain goat or still more fetid man, 



(a) B^champ et Ritter, compt. rend, de l'Acad. des Sc, 2 novembre 1872. 

Bouchardat, De l'uree (these d'Agreg., 1869).— Hirtz, art Fievre (Diet, de mdd., t. iv, p 707). Murchis- 
son, Diseases of the Liver, p. 72.— Brouardel, Arch, de physiol., 1876. — Charcot, Lecons sur les maladies 
du foie. 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 273 

In order to give system to the exposition of this subject, I shall consider 
it under several heads, and examine successively the treatment of gouty 
paroxysms, the treatment of gout apart from the paroxysms, and finally the 
hygienic and thermal treatment which occupies the first place among the pro- 
phylactic means. 

Gout, as you know, manifests itself in paroxysms, 5 and without giving you 
here a symptomatic description of these attacks, which have never been more 

Colewort, or gypsum, or the well-ground sand 
Of Asia's powerful stone, with bean-flour mixed, 
Others, sagacious tribe, call in the aid 
Of weasels, toads, hyenas, ruddocks, stags, 
And foxes; every metal, and the teas 
Distilled of every tree; bones, nerves, and skins 
Of every beast, milk, urine, marrow, blood. 
A portion some of four ingredients, some 
Of seven or eight prefer, some oft repeat 
The sacred bitter; some to the pure spring 
Medicinal, whilst others trust to charms 
And incantations, which the wand'ring Jew 
Hath ever ready for his gaping throng. 
Meantime I laugh and bid the fools go weep, 
Who mock me thus, and but incense my rage, 
Whilst to the humble, who oppose me not, 
I'm ever mild and gentle." (a) 

5 Gout may be divided into acute and chronic, normal and abnormal, simple or com- 
plicated. Acute gout manifests itself by energetic attacks, separated by variable intervals. 
Gout is normal, that is to say, regular when it affects only the joints; abnormal when it 
appears only under the form of metastatic visceral accidents; complicated, when to the joint 
symptoms are added visceral affections. The first fit of gout comes on ordinarily between 
the ages of 30 and 35, but it may be for a long time preceded by certain morbid phenomena 
which are under the influence of the gouty diathesis, such as gravel, neuralgic pains, 
migraine, gastralgia with pyrosis, certain dermatoses, such as acne, eczema, psoriasis, etc. 
These phenomena constitute what has been sometimes described under the head of larvated 
gout. 

The first paroxysm may be ushered in by certain prodromes consisting especially 
in dyspeptic symptoms, but the invasion is generally abrupt. The patient goes to bed 
the evening before in good health and falls asleep, then at the end of several hours he is 
awakened by a pain of greater or less severity, seated in the metatarso-phalangeal articula- 
tion of one of the great toes, ordinarily the left; he has at the same time a slight chill, the 
pain soon increases in violence, and becomes atrocious, with sensations of burning, throb- 
bing, stinging, tearing, etc., then little by little it becomes subdued, perspiration breaks out, 
and the patient goes to sleep. On awaking, the toe is found inflamed, the skin is red, 
swollen, of shiny aspect, sometimes livid and furrowed with vessels distended with blood; 
the whole joint is painful to pressure and to movement. The fit is over. During the day 
the morbid symptoms are absent, and the patient thinks himself well, but the following night 
the pain returns, at first dull, then with the same acuteness as the night before. For several 
days the attacks may thus burst forth every evening and cease in the morning. When the 
paroxysms are nearly over, the fits are less violent and shorter, the great toe takes on a 
bluish hue, the tumefaction, the oedema, the redness cease, and there is a desquamation of 
the epidermis. In the interval of the fits of one attack, if during the day the pain is COm- 



Crt) From Lucian's Gout-Tragedy, Francklin's translation. 



274 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

admirably portrayed than by Sydenham in his treatise 6 on gout, I will mention 
especially the dyspeptic prodromes and the pains in the joints which acute gout 
determines. 

The perturbation of the functions of the stomach plays a considerable part 
in the attacks of gout, and this is so generally known that gout has even been 
attributed to functional derangements of the stomach. I have already spoken 
of these gouty dyspepsias in those lectures which treat of diseases of the 
stomach. 

As for the pains in the joints, these affect, as you well know, in the great 

pletely alleviated, the digestive functions remain good, but if the case is otherwise, there is 
anorexia and dyspeptic disorder. 

During the febrile paroxysm the urine is scanty, and deposits a great quantity of crys- 
tallized uric acid (Scudamore, Proust, Rayer). 

The first attack of gout may be the only one, but this is not generally the case, and 
often at the end of several months there is a second, then a third, then other attacks occur 
at intervals more or less wide apart, and leave certain traces behind them. The gout does 
not remain limited to one joint, it attacks several; resolution is not complete in the diseased 
parts; the joints keep stiff, are tender and sensitive to pressure and movements; the gout 
passes to the chronic state. 

Chronic gout may be chronic from the outset; generally it succeeds the acute form. 
The attacks are less violent and are apyretic, but they are longer, and in the interval of the 
fits the health does not become fully restored as before. The local state undergoes changes; 
in the ligaments and periarticular tissues there are deposits of urates. Concretions appear 
under the form of fine sand, or mortar like masses, which are diffused among the tissues, 
become hard and form solid bodies, sometimes of considerable size, which provoke disorders 
more or less, grave on the part of the joints, distort the bones, and render movements 
impossible. In the feet the tophus has its favorite seat around the first joint of the great 
toe. When the disease has lasted a long time, it is quite common to note other alterations. 
The articulating surfaces may be disjoined, concretions of urates and of uric acid cause 
incomplete luxations, the bones themselves are affected, and anchyloses ensue; sometimes 
the periarticular tophus becomes the origin of inflammation, followed by ulcerations of the 
skin, which lead to sloughing out of the concretions. These lesions are met with chiefly in 
fixed gout. The cretaceous deposits are not only found in the bones, joints, and periartic- 
ular tissues, they are also observed in the cartilages, and Garrod relates cases of gouty 
patients who had no joint troubles, and where but one or two patches were observed of urate 
of soda seated on the cartilage of the external ear. 

6 Sydenham's description of the fit of acute gout is as follows : 
"Whenever the gout is regular, this is its mode of manifestation: 

' 'About the end of January, or the beginning of February, it bursts forth abruptly, almost 
without warning, if we except a certain crudity of the stomach with dyspepsia, from which 
the patient has for several weeks suffered. He has been (it may be) complaining of a feeling 
of flatulent distension, and of a heavy pressure, which increases from day to day till the fit 
occurs. For a few days he has suffered from a sense of torpor, with cramps or muscular 
spasms running down the limbs. Sometimes the evening before the attack, the appetite is 
more voracious than natural. He goes to bed, however, in a fair state of health and sleeps. 
About two o'clock in the morning he is awakened by a pain which is generally confined to 
the great toe, sometimes to the heel or the calf of the leg. This pain resembles that which 
accompanies dislocation of these bones, plus the sensation of hot water poured on these 
parts; so6n a creeping sensation with a chill comes on, and a little fever. The pain, at first 
moderate, gradually increases, while the crawling sensations and the chill disappear. At 
length, as the morning comes on, the pain arrives at its maximum, spreading over the differ- 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 275 

majority of cases, the metatarso-phalangeal articulation of the great toe, and 
cause horrible suffering. The skin over the inflamed joint takes on a violace- 
ous tint, and has a shining aspect which enables you to diagnosticate a fit of 
gout at first sight. You know to-day that these joint phenomena are due to the 
presence in the interior of the articulation of crystals of urate of soda, and you 
are aware that the least disturbance of the limb will exasperate the pain; you 
also know that the urate of soda, the morbific agent of the gout, may cause 
certain saline deposits, known as tophus, around the joints. 

But there is a disputed question which we must now meet, viz., whether it 
is best to treat at all a fit of gout. Moved by the grave accidents which may 

ent bones of the tarsus and metatarsus and gaining possession of the ligaments, sometimes 
manifesting itself under the form of violent tension or laceration of these investments, or 
gnawing, racking, rending torture. 

The part affected has acquired so exquisite a sensibility that it cannot bear the weight 
of the bedclothes, nor even the jarring produced by a person heavily walking across the 
room. The night passes in this excruciating suffering and in perpetual jactitation of the 
entire body. The patient vainly seeks for rest, and for some easy position for the suffering 
member, and relief does not come for several hours, or till after a sort of 
digestion or dispersion of the morbid matter. The patient at last feels a sudden lull in the 
pain, and generally he attributes it, though wrongly, to the last position in which he placed 
the painful member. 

Covered with a gentle perspiration, he yields to sleep. On waking, the pain is very 
much lessened, but he perceives that the affected part has become the seat of a tumefaction, 
while previously there was nothing to be seen but swelling of the veins in the vicinity. The 
next day, or two or three days later, according as the matter suitable to engender the gout is 
more or less abundant, the part attacked remains more or less painful; the suffering aug- 
ments towards night and diminishes towards morning. At the end of two or three days 
the other foot is tormented by a pain similar to that which affected the first member. If the 
latter is now free from pain, the resulting debilitation soon vanishes; the bodily forces are 
restored as before, unless the pains which affect the second member should become equally 
atrocious, in which event there would be a renewal of the previous scene of suffering. After 
the two feet have been thus affected, the successive paroxysms become abnormal as respects 
the time of the invasion and the duration. They keep always this characteristic, that the pain 
has its nocturnal recrudescences and its morning remissions. 

It is the congeries of these fits which constitutes the paroxysm of gout. It is not to be 
inferred that the individual afflicted by the malady for two or three months is all the time 
under torture; he is subjected to a series of paroxysms which go on decreasing in severity 
and duration till the peccant matter is exhausted and the health is restored. 

In strong individuals and those whom gout has rarely visited, this return to health 
often takes place after a fortnight; in old men and those who have often been afflicted by 
the disease, it is accomplished at the end of a couple of months. Those, in fine, who have 
become infirm from age, or in consequence of long subjection to the disease, do not generally 
experience any improvement till summer. 

The first fourteen days the urine is more highly colored than natural, and on standing it 
deposits a red and sandy sediment; the patient scarcely gets rid of a third of his ingested 
liquids by the urinary passages; the constipation is almost constant. The loss of appetite, 
the chilliness experienced toward evening, the sensation of weight and of malaise even in 
the parts which have not been affected, are continued throughout the sickness. Towards 
the end there comes on an almost intolerable itching of the foot, especially between the toes 
where there is a furfuraceous desquamation. The feet themselves undergo desquamation 
just as after certain poisonings. 

The sickness is over, health and appetite return, and this in proportion to the pain 



276 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

occur in the case of a gouty paroxysm, and especially struck by the disappear- 
ance of the gouty symptoms when visceral complications arise, the older physi- 
cians assigned an important part to metastasis in the production of these phe- 
nomena of visceral gout. Adopting in their entirety the ideas of Sydenham, 7 
they thought that it was dangerous to interfere in the gouty paroxysm for the 
reason that the attack was the result of a tendency on the part of the economy 
to throw out peccant humors; if this elimination did not take place, they 
thought that this morbific matter, attacking the lungs, heart, and brain, would 
produce very serious complications referred by them to retrocession. 

Thanks to the progress of pathological anatomy, we have an explanation 
more true, more scientific, and more exact of this metastasis, and we know to-day 
that it is occasioned by uraemia. In fact, the kidney plays an important rdle in 
the symptomatology of gout. Under the influence of the constant irritation 
which is determined by the passage of urine loaded with uric acid, the renal 
canaliculi become inflamed or obliterated in part, and then supervenes either 

and discomfort experienced during the long attack. If the last attack seriously prostrated 
the patient, the next one will not reach the same point of severity during the year following. 
This is the behaviour of regular gout which manifests itself with the frank symptoms which 
are proper to it. (a) 

7 Gout, whether acute or chronic, is not always regular, is often unfortunately 
abnormal, and the articular fluxions may be replaced by visceral troubles. 

The articular crises may cease abruptly, the pains disappear; whereupon sundry metas- 
tatic affections manifest themselves: dysentery, enteralgia, cardialgia, angina pectoris, peri- 
carditis, endo-carditis; the breathing may be asthmatic; on the part of the brain there may 
be delirium, apoplexy, coma, ending fatally. 

The visceral manifestations may also appear in the interval and independently of the 
fit of gout (alternating or sub-articular gout). 

The abnormal manifestations of gout pertain to divers systems and functions, and the 
following kinds of gout have been aescribed: 

i. Gout of the muscular system (myosalgia, paralysis, contracture). 

2. Gout of the nervous system (cephalagia, cephalia, melancholia, hypochondriasis, 
oddities of character, frontal, facial, sciatic neuralgia, etc.) 

3. Gout of the respiratory and circulatory apparatus; pulmonary or bronchial con- 
gestions, asthma, nervous palpitations, cardi-algia, angina pectoris, gouty heart, fatty 
degeneration of the heart, atheroma of the arteries, whence ensue haemorrhages, cerebral 
or spinal ramollissement, constituting gouty apoplexy or gouty paraplegia. 

4. Gout of the digestive apparatus (gouty dyspepsia), characterized by pains, gastral- 
gia, eccentricities of appetite, pyrosis, vomiting of glairy mucous, intestinal pneumatosis, 
enteralgia, constipation, hsemorrhoids, hepatic congestion, biliary lithiasis. 

5. Gout of the genito-urinary apparatus; gouty kidnev (gravel, renal colic), gout 
of the genital organs (blenorrhcea. retention of urine), gout of the skin (arthritides). 

Chronic gout, by the disorders which it produces, by the trouble which it provokes in 
the organism, may reduce the patient to cachexia. Exhausted by the pain, condemned by 
immobility, sometimes complete, by reason of the articular lesions, he leads a languishing 
life; appetite fails, the stomach no longer digests the food which oppresses it, and the patient 
grows feebler from day to day, unless some intercurrent disease or complication supervenes 
to put an end to his sufferings. 



(a) Sydenham, Tractatus de podagra, 1683. Lasegue, Traite de la goutte de Sydenham, partie descrip- 
tive, Paris, 1882, p. 7. 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 277 

interstitial nephritis, or fatty metamorphosis of the kidneys, and it is to this 
aggregate of lesions that the name of gouty kidney has been given. These 
lesions, by impeding the functions of the renal filter, entail consequences more 
or less grave, some pertaining to uraemia, others having a marked influence on 
therapeutics, and explain why certain medicines administered to the gouty, 
have even been attended with fatal results. 

We find here also an application of a fact to which I have called attention 
before in the course of these lectures. It is that when elimination by the kid- 
neys is at fault, you obtain not the medicinal effect desired, but the toxic action of 
the substance which you employ. This, too, explains why our forefathers were 
afraid of active interference in gout; it also shows the necessity of great prudence 
in the treatment of this disease, and careful daily examination of the urine, and 
this, not only with reference to the albumen which it may contain, but also to 
the extractive matters in that excretion. These reserves being made, I believe 
it to be the duty of the physician actively to treat attacks of gout, discarding 
altogether the precept of Cullen, who summed up in the two words, "patience 
and flannel," the whole treatment of gout. 

A great number of medicaments have been proposed for acute gout — anti- 
phlogistics, purgatives, sudorifics, specifics, etc. Bloodletting, whether general 
or local, once much in usage, as, for instance, in the celebrated remedy of 
Paulmier,' which consisted in the application of twenty or thirty leeches 
around the joints, is completely abandoned. Nevertheless, Garrod thinks that 
in certain exceptional circumstances one may have recourse to local emissions of 
blood with advantage, and Gairdner is of the same opinion. However, it is 
not easy to see what good this local bleeding can have in acute paroxysms, 
being powerless to modify the uric diathesis — the cause of the affection. 

As for sudorifics and purgatives in this disease, their value has long been 
discussed. Among the first, guaiacum deserves a place, once of great reputation 
as a specific in gout, and Ackermann, Metzger, Weismantel, have vaunted its 
anti-arthritic properties. The essence of guaiac serves as the basis of the cele- 
brated remedy of Caraibes, the anti-gouty syrup of Boubee, and the syrup of 
Vicq d'Azyr and of Gall. 2 

1 Sydenham, who was a great partisan of blood-letting in rheumatism, does not ap- 
prove of it in gout, except during the first attack. Todd thought that bleeding favored 
metastasis. Gairdner, on the contrary, approves highly of blood-letting, and affirms that he 
has met with cases of atonic gout with plethora, before which he found himself powerless 
without the help of blood-letting, which brought instantaneous and complete relief. 

The remedy of Paulmier consists in applying from 20 to thirty leeches around the 
joints. Roche maintains that the application of leeches may cut short an attack of gout; it 
will at least shorten the sickness. 

2 The famous remedy of Caraibes is principally composed of the alcoholic tincture of 
guaiacum. The anti-gouty syrup of Boubee has this formula : 

I£ Sarsaparilla root 40 parts. 

Resin of guaiacum 15 

Jalap g 

Mustard 9 " 

Mix. 



278 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

To-day guaiacum is almost completely abandoned, and if it were desir- 
able to resort to sudorifics it would be better to employ jaborandi and pilo- 
carpine. But although urea does to some extent undergo elimination by per- 
spiration, this elimination is too insignificant to afford a real relief to the 
patient, and while recognizing that it is a good thing to promote the functions 
of the skin during the fit of gout, I do not think that we can count much on 
sudorifics to the exclusion of other remedies. 

It is the same with purgatives, to which Scudamore had attributed curative 
virtues in the attack of gout, while Sydenham, on the contrary, discarded 
them altogether. Purgatives have no other effect during a fit of gout than to 
keep the bowels open, and this is generally necessary by reason of the consti- 
pation which is habitual in such cases. The purgatives to which you should 
always have recourse are chiefly mineral waters, such as those of Hunyadi 
Janos, Ptillna, Carlsbad, the American Hathorn water, etc., which should be 
given only in sufficient quantity to maintain regular action of the intestines. 

I pass rapidly over mercurial treatment, vaunted by Musgrave and Hamil- 
ton; antimonials which serve as a basis for Quarin's cure (of Sarza, licorice, 
anise and antimony), and James's powder (of precipitated antimony and 
phosphate of lime), to come to medicaments which have a real specific 
action in gout. I refer to sulphate of quinine, to colchicum, and to salicylate 
of soda. 

Influenced by the intermittency which characterizes the gouty paroxysm, 
quinine has been recommended in its treatment, and it is doubtless true that 
this medicine mitigates, to some extent, the intensity of the attack. Quinine 
may be given with other medicines, and especially with colchicum. Colchicum 
is the veritable specific in gout, and Fievee has gone so far as to affirm that 
colchicum is to gout what quinine is to fever and ague. Nevertheless, colchi- 
cum is absolutely an empirical medicine, for if clinical experience every day 
witnesses its good effects in gout, experimental physiology has little to say in 
explanation of those effects. 

Colchicum is a bulbous plant with violaceous flowers, which flourishes in 
abundance in our meadows, and which our herds carefully shun, for it consti- 
tutes for them a poison of great activity. 3 The bulb, the seeds, and the flowers 

Boil in three hundred parts of water for two hours, and add sugar enough to form 
a syrup. 

The anti-arthritic pills of Vicq d'Azyr have also guaiacum for a basis; the formula 
is as follows: 

i^ Castile soap 4 parts. 

Ox gall 2 " 

Mix and incorporate guaiacum resin, calomel, of each 1 part. 

M. — Make into pills each weighing 20 centigrammes. Dose, one or two morning and 
evening 

The pills of Gall contain, besides the extract of guaiac, a little antimony and opium. 

3 Colchicum is an emeto-cathartic medicine. Its mode of action on the kidneys and 
circulation is under dispute. While Hammond, Christison, Maclagan, Bouchardat and 
others claim that colchicum acts as a diuretic and augments the excretion of uric acid and 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 279 

are used in medicine, being made into tinctures, alcoholic extracts, and wines, 
which are the modes of administration most often employed. As the different 
parts of the plant do not contain the same quantity of active principle, it is 
necessary to specify in your prescriptions the part of the plant which you desire 
to administer. Although the tincture of the flowers, known under the name of 
Hahnemannian tincture, has been vaunted by several authorities, and in par- 
ticular by Debout, it is generally preparations of the seeds which you should 
order, and you can administer the tincture and the fluid extract in the dose of 
ten drops to a teaspoonful daily watching carefully the result of your doses, 
for the therapeutical effect varies according to individuals. Some can bear 
large doses without inconvenience, while others experience toxic results from 
very small doses. These troubles consist, as you know, in diarrhoea and vomit- 
ing; these effects you should avoid. You ought then to order the tincture 
of colchicum in doses consisting of a certain number of drops, remembering 
that twenty drops weigh thirty-nine centigrammes. You can give twenty 
drops morning and evening without any inconvenience, and increase the dose 
according to the needs. 

But you will ask, since the active principle is unequally distributed in the 

urea, Gairdner, Garrod, Oberlin, Boecker, affirm that it does not act on this excretion 
which is the rather diminished according to Garrod. These are, moreover, Garrod's con- 
clusions: 

i. There is nothing to prove that it is one of the effects of colchicum to provoke 
an increased elimination of uric acid; when this medicine has been continued for a long 
time it seems, to produce the contrary result. 

2. We cannot affirm that colchicum has any influence on the excretion of urea or any 
of the other solid principles of the urine. 

3. Colchicum does not always act as a diuretic; on the contrary, it often diminishes 
the quantity of urine, especially when its action on the digestive tube is very marked. 

Graves pretends that colchicum if it does not act as diuretic, prevents the production of 
uric acid in the blood. Bouchardat and Maclagan claim that colchicum has a sudorific 
action. 

The action on the heart is still more uncertain. According to some authorities, as 
Albers, of Bonn, the movements of the heart undergo no change under colchicum, while 
Maclagan and Garrod have always noted a diminution of the pulsations in man. 

In fine, colchicum and colchicine act, according to Albers, as paralyzers of the sensibility 
and motor functions. 

Jolyet, on the contrary, maintains that it is an excito-motor medicament analogous 
to strychnine. 

Nothnagel and Rosbach pretend that colchicine acts very slowly and determines the 
death of animals; three centigrammes suffices to kill a man. The heart is not in- 
fluenced by colchicine, but the medicament acts on the nervous system, producing complete 
paralysis, (a) 



{a) Garrod, la Goutte, son traitement (trad, par Ollivier, Paris, 1876, p. 445").— Maclagan. On Colchicum 
Autumnale in Monthly Jour, of Med. Sc, t. xiii, 1851, et xiv, 1852). — Boecker, Beitreege zur Heilkunde, t. n, 
p. 204. — Hammond, Experiments Relating to Diuretic Action of Colchicum (in Glasgow Medical Journal, t. 
ix, 1861). — Jolyet, De Taction physiologique de la colchicine chezla grenouille (Compt. rend, de l'Acad. des sc. 
et Me"m. de la Soc. de biol., 1867). — Albers (de Bonn), Deutsche Klinik, 1856. — Goupil (de Rennes) Memoire 
sur le colchique d'automne, son action physiologique, ses effects therapeutiques dans le rhumatisme et dans la 
goutte (Arch, gen de med., se seYie, t. xviii, p. 57, 1861, et Bull, gen de ther. t. lxi). — Nothnagel et Rosbach, 
Elements de matiere medicale et de therapeutique (trad, par Alquier, Pans, 1880, p. 681). — Dujardin-Beaumetz 
Dictionn. de Ther., art. Colchique. 



280 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

plant, why not give this active principle itself? Here we find ourselves in the 
same embarrassment as in the case of digitalis; and just as there have been 
found several digitalines, so there have been found several active principles in 
colchicum. Hess and Geiger, for instance, have extracted from colchicum, 
colchicine; Oberlin, colchiceine; Hubler, still another alkaloid; so that the ques- 
tion of the veritable active principle of colchicum is still undecided. There- 
fore, in the midst of this uncertainty, I think it is better, as in the case of 
digitalis, to employ the plant itself, indicating, as before said, the tincture of 
the seeds, or root, or whatever other preparation you wish to employ. The 
tincture of colchicum may be associated with other substances, and it is this 
combination which characterizes the majority of the popular remedies for gout, 
such as Laville's tincture (liqueur Laville), the wine of Anduran, the tincture of 
Cocheux, the pills of Lartigue, and many others which I pass over in silence. 
If you do not desire to recommend any of the proprietary nostrums, you 
can prescribe combinations just as useful, such as the following, which is a good 
formula : ' 

The European ash has had a great reputation in the treatment of gout, and 
Pouget and Peyraud consider it as a genuine specific. Moreover, the number 
of indigenous plants regarded as antiarthritic is considerable, and, to give you 
an idea how numerous they are, you have only to refer to the electuary 2 once 
vaunted by Sydenham (this electuary consists of twenty-nine articles). Among 
these plants I will mention only one — aconite — whose administration mitigates 
the pams from which gouty patients suffer; therefore, I think that it is always 
well to combine aconite with your colchicum. Alkalies have little curative 
action in acute attacks of gout, and constitute only an adjuvant medication. 
During my trials with propylamine and trimethylamine, I obtained in certain 
patients (and in particular an illustrious marshal of France) disappearance of 
the gouty attack under the influence of these medicaments; but now these 
ammoniacal compounds deserve to give place to a medicine much more ener- 
getic and certain, viz., salicylate of soda. 

Salicylate of soda has an evident curative influence in gouty paroxysms, and 
it owes its action to several causes: first, because it favors elimination of urea 
and uric acid (you know, in fact, that salicylic acid is eliminated in the urine 

1 1$ Tincture of colchicum, 

Alcoholic tincture of aconite root, 
Compound tincture of jalap, 
Tincture of quinine — aa § ss. 
M. Sig. — Thirty drops, morning, noon and night, in a wineglassful of some bitter 
potion, such as infusion of fraxinus excehior. 

2 Sydenham vaunted highly the following electuary: Take of angelica root, sweet cane 
masterwort, elecampane, absinthe, centaury, white horehound, germandry, ground-pine, 
calamint, matricaria, meadow saxifrage, St. John's wort, golden rod, wild thyme, pepper- 
mint, sage, rue, blessed thistle, pennyroyal, southernwood, flowers of tansy, lily of the 
valley, saffron, grains of thapsia, cochlearia of the gardens, caraway seeds, and juniper 
berries; of each a sufficient quantity. Take of each of these plants six ounces, and enough 
honey and Canary wine to make the electuary of the required consistence. Give of this 
every morning and evening about a tablespoonful. 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 281 

under the form of salicyluric acid); next, because this medicament is a powerful 
analgesic of the articular pains; and, finally, because it has an antipyretic action 
similar to that of quinine. Therefore, German See 1 has rightly insisted on the 
advantages which may be derived from salicylate of soda in the treatment of 
attacks of gout, and here the rules of administration are the same as for acute 
articular rheumatism. But it is necessary in these cases to pay particular atten- 
tion to the state of the kidneys, for, as I have already told you, the imperme- 
ability of the renal organs may render the administration of salicylates danger- 
ous, and this it is that explains the divergence of opinions which have been put 
forth respecting the advantages and inconveniences of this medication in gout. 
The external treatment of gout is a matter of much less importance than 
internal medication. Many local means 2 have been recommended in the acute 
paroxysms, from ointments and pomades in current use, to more complex for- 
mulas, and even to horse-chestnut oil; from applications as hot as can be borne, 
to the use of ice around the joints; — all have been counselled in these arthritic 
inflammations. I believe, and in this I am supported by Garrod, that all these 
applications are useless, and even dangerous. It suffices to consider the state 
of these joints, the fiery redness of the skin around them, the pain of which 
they are the seat, to convince one that frictions of an irritant nature may inflict 
grave disorders on the cutaneous surface thus inflamed. Therefore, in view of 

1 Germain See explains the favorable action of salicylate of soda as due to its analgesic 
power, to its revulsive or resolvent actiqn. to its eliminating properties in certain cases, and 
also to its power of destroying glycocol, which constitutes an albuminoid excretory sub- 
stance of considerable importance. According to him, the salicylic medication ought to be 
employed from the commencement in an attack of gout. 

The best mode of employ consists in the administration of a drachm and a half daily 
during the first three days, of one drachm daily during the three following days, and 
alternating in this way each successive three days, for three weeks. 

Out of one hundred gouty patients whom he has treated by salicylate of soda, he has 
had four or five failures, and out of the ninety- five remaining cases, more than half were 
cured immediately. 

See's view is not shared by all physicians. Lecorche has obtained very unsatisfactory 
results. Freney and Gueneau d'Mussy, have observed grave complications following the 
salicylic medication. Bouloumie, in six gouty patients treated by the salicylate, noticed no 
favorable results, (a) 

2 Various local measures have been employed against gout; Cartwright used blisters. 
The fly blister was also a secret remedy which made the reputation of a woman of Horsham. 
Turck employed lotions of albuminate of potash. Scudamore recommended applications of 
tepid water. Others, as Harvey, Small, and Bouchut extol applications and irrigations with 
cold water. Galtie Bossiere made use of carbonate of potash; Goeden, frictions with phos- 
phorus; Bartella, compresses saturated with chloroform. Then we come to the more com- 
plex formulas, one of the most noted of which is the remedy of Pradier. This consists in 
the application to the member of a large flax-seed poultice wet with a lotion composed of 
balm of mecca, red cinchona bark, saffron, sage, sarsaparilla and alcohol. The tincture ob- 
tained by this maceration was also given internally, {b) 



{a) G. See, on "The Treatment of Acute and Chronic Rheumatism and Gout, Paris, 1877. Bouloumie\ 
on " Salicylate of Soda, and its Employ in the Fit of Gout (Union Med., May 15, 20, and 25, 1879). 

(<5) Garrod, De la goutte et de son traitement, trad. d'Ollivier, Paris, 1867, p. 421. Monneret et Fleury, 
Compendium de MeMecine, t. 11, p. 359. 



282 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

the trifling benefit of these local applications on the one hand, and their danger 
on the other, I advise you to discard all these pomades and ointments, and to 
surround the foot with a layer of finely carded cotton, which will give immo- 
bility to the affected joints and protect them from the air. 

To sum up then, when you are called to treat an attack of gout, you should 
first assure yourself of the integrity of the kidneys, then you should administer 
salicylate of soda in doses of from one to one and a half grammes, or, if you 
prefer, the tincture of colchicum combined with quinine or strong tincture of 
aconite root. If, on the contrary the kidneys are damaged, or if the heart 
seems to be degenerated, you will have to content yourselves with giving 
alkaline diluents and keeping the bowels open with saline purgatives; besides 
enswathing the affected member with wadding around which is placed oiled 
silk. 

But it is not enough to combat the attack of gout, something must be done 
to prevent its return, and here we have many means at our command, both 
pharmaceutical and hygienic. Whatever theories may be admitted in explana- 
tion of uricaemia, it is against this condition that all our efforts should be 
directed; here then is the place for the alkaline medication under all its forms. 
I will be more brief in the exposition of this part of my subject, because I have 
already, in a former lecture, spoken to you of the treatment of the uric acid 
diathesis. 1 

All the alkalies may be employed, soda as well as potassa, but there is one 
that seems to be better than all the others,- viz: lithia, which Garrod recom- 
mends. I need hardly tell you that the dose of carbonate of lithia is seven or 
eight grains (fifty centigrammes) given at meal-time in carbonic acid water; the 
effervescent salts of lithia are good preparations. Benzoic acid and the benzo- 
ates have also been highly extolled, and combinations of benzoic acid with 
alkalies are in use, such as the double benzoate of soda and lithia, which is an 
excellent preparation. 

By the side of the alkaline medication, certain tonics and stomachics de- 
serve a place, being much in repute. These are principally bitter preparations 
furnished by our indigenous flora, constituting antiarthritic remedies more or 
less complex, such as (to name those most known) the " electuary of Syden- 
ham " which I have before mentioned, and the famous remedy of the " Duke of 
Portland." These nostrums, once the subject of much discussion, have now 
happily passed into oblivion, and given place to quassia and cinchona bark, 
which are of some little efficacy in atonic gout. 

As you perceive, the pharmaceutical treatment of gout in the interval of 
the attacks is limited to the administration of alkalies in all their forms and 
and bitters and other tonics. Add to these means the thermal treatment, which 
plays a considerable part in the therapeutics of this disease. Three stations 

1 Garrod has been enthusiastic in extolling the salts of lithium in the treatment of gout. 
The salts the most employed are the carbonate and citrate, these salts have a double thera- 
peutic action; they produce marked diuresis, and they form with uric acid a compound 
essentially soluble which is easily eliminated. Garrod employs this medicament with suc- 
cess, both internally and in the form of local applications to the inflamed joints. 



ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 283 

among all those which have been considered as suitable for podagrous patients 
ought to attract your attention, viz: Vichy, in France; Wiesbad, in Germany; 
Carlsbad, in Bohemia. 

There has been much discussion concerning the mode of action, the ad- 
vantages and disadvantages, of Vichy water in gout. To-day this question 
seems to me decided, and I have already given expression to my views on this 
subject under the head of " renal lithiasis." It is not by neutralizing the excess 
of uric acid that these alkaline waters act, it is by their influence on the general 
nutrition, whose functions they regulate. But I am well aware that it will not 
do to exceed certain quantities, and that the treatment by alkaline mineral 
waters is not altogether unattended with evil. You should then send to Vichy 
your strong and plethoric patients whose nutritive functions are below par, and 
you should proscribe these waters to weakly patients whose attacks are but little 
accentuated — in a word, who have the symptoms of what has been described 
under the name of atonic gout and gouty cachexia. 

The Carlsbad waters act like those of Vichy, always with this difference, 
that they are purgative. They suit admirably gouty patients with hepatic con- 
gestion and gastro-intestinal troubles, characterized by constipation or irritation 
of the stomach and bowels, provoked by excesses of the table. Weisbad belongs 
to the sodic chloride waters, and is applicable rather to the arthritic diathesis 
than to gout itself. The Aix la Chapelle waters, as well as those of Ems and 
Royat, which are all sodic chloride waters, act also by the lithia which they 
contain, and combat rather the multiple manifestations of the arthritic diathesis 
than the excess of uric acid itself. These are very useful spas, to which you 
would do well to refer a large part of your chronic rheumatic patients. 

Hygiene plays a considerable part in the prophylactic treatment of gout. 
Everybody is agreed that gout, aside from the laws of heredity, is the conse- 
quence of defective hygienic conditions; the uric diathesis, which is its starting 
point, being an evidence that the azotized materials introduced into the 
economy there undergo an incomplete combustion. We have, then, two great 
factors in the pathogeny of gout: too abundant alimentation, too little muscular 
exercise. Gout is a disease of the rich, 1 and this is a fact on which have 
insisted all writers, from the most remote antiquity. You should, then, have a 
care over the alimentation of your gouty patients, and proportion it to their 
muscular work. You should look after not only their solid food, but also their 
daily beverages, 2 alcoholic excesses having an important influence in the 

1 It would take a whole volume to include the substance of what has been written 
respecting the influence on gout of excesses in diet. Petrarch says, " If you wish to live 
free from gout, you should be poor, or live like a poor man." Sydenham expresses himself 
thus: " Gout has this in particular which distinguishes it from all other diseases: that it kills 
more rich people than poor people, and more men of wit than men of dullness and stupidity." 

Gout has also been called " morbus dominorum." 

VanSwieten has this sentence appertaining to gout: il Ut divitiarum pedibus bene culta 
sedit." 

Like excesses of the table, excessive venery has been accused of giving rise to gout: 
" Unde Bacchi et Veneris filia salutatur a poetis podagra" 

2 There has been much discussion concerning the nature of the wines which have been 



284 ON THE TREATMENT OF CHRONIC RHEUMATISM AND GOUT. 

etiology of gout. In fact for ages, attention has been called to the influence of 
spirituous liquors on the development of this disease. Wines that contain too 
much alcohol, as well as strong beers, should be interdicted altogether; although 
Garrod has condemned cider, I do not believe that this beverage can give rise 
to gout; I think there may be cases in which it may be beneficial. 

But if the dietary of the gouty patient needs to be carefully regulated, it is 
just as necessary to prescribe suitable muscular exercise of all kinds; gymnastics, 
fencing, pedestrianism, all should be employed, and as our immortal fabulist 

has said: 

" Goutte bien tracassee, 
Est, dit on a demi pansee." 

prescribed or forbidden gouty persons. Van Helmont condemns the white and sour wines; 
the white wines of Bohemia and of Hungary are also forbidden. Champagne, according to 
Scudamore, is even more detrimental. Nevertheless, Bouchardat is of the opinion that the 
white and moderately sour wines, cut with the alkaline waters, are very useful in the case of 
polyuria. 

Beer is absolutely proscribed by Garrod; Van Sweiten, however, claims that it is useful, 
But there is a general agreement in proscribing the alcohols, so-called, and liquors. Rabu- 
teau has even pretended that alcohol in the blood precipitates uric acid. 

[Dr. J. Mortimer Granville {Lancet, Aug. 16, 1884) has an interesting article on the 
" Mental Element in Gout," in which he sets forth the view which he says is accepted gen- 
erally, now "that there is a uric acid centre, either eliminative or destructive," probably 
located beneath the floor of the fourth ventricle, not far from and in functional relation with 
the so-called diabetic and polyuric centre. An attack of gout is likely to occur in the gouty 
subject at either of two mental or cerebral crises. First, on the eve of a great mental effort, 
when the brain is charged to the highest point of tension with " nervous energy." The type 
of a paroxysm so occurring is likely to be "nervous," with severe neuralgic pains, if the 
patient be neurotic, or visceral, in the sense of attacking one of the large organs, if he be 
robust or of active habit. Second, an attack of gout is likely to occur at the end of an intel- 
lectual effort, when the centres are exhausted, and in this case it may take on the form of an 
epileptiform fit, or syncope, followed by more or less prolonged depression, or it may rapidly 
develop into a formulated arthritis of the ordinary type. In the break-down, before action, 
he thinks the cerebral strength itself gives way; while in the paroxysm, after exertion, the 
attack occurs because the inhibitory control of the cerebral centres over the spinal medullary 
and organic centres is suddenly suspended. The former class of cases is the most serious, 
and attacks of this kind go far to prove the existence of a neurosis, for which the patient will 
require to be specially treated. The second class is one in which the malady proper rather 
than the patient demands the practitioner's greatest attention. His therapeutic suggestion 
is that the uric acid can only be got rid of by a process of oxygenation, and that it must 
pass off by the kidneys, and not by the bowels. Purgatives in gout are always harmful in 
direct proportion, as they promote discharge of fluid from the intestinal surface, and leave 
the urine concentrated so that the uric acid, which requires a very large amount of fhiid for 
its elimination, blocks the tubes of the kidneys in the form of crystals. One reason for the 
specially frequent occurrence of gout in warm weather is the loss of fluid by perspiration, 
and the consequent concentration of the kidney excretion. If uric acid can crystallize, it will. 
Below is Granville's famous anti-gouty mixture, which he says always immediately relieves 
pain,, reduces swelling and raises the proportion of urea in the urine, as estimated by the 
hydrobromate test, from 50 to 100 per cent, in a few hours. He never starves patients or 
gives colchicum, believing nitrogenous food to be necessary, a vigorously trophic state being 
needful to facilitate the oxidation of uric acid. 5 Ammon. chlorid, 3 iv. Pot. chlor., 
3 ij. Glycerine, 3 xij. Tinct. iod., 3 ij. Aquam ad, \ xij. M. Sig. Take two table- 
spoonfuls every third, fourth or sixth hour. Granville's theory, in the present state of sci- 
ence, can be looked on as only an ingenious and plausible speculation, provisionally, per- 
haps deserving acceptance. — Translator.] 



ON THE TREATMENT OF DIABETES. 

Summary. — Concerning Diabetes — Its Frequency — Its Pathogeny — Physiological Glycsemia 
— Theory of Diabetes — Alimentary Theory — Nervous Theory — Theory of Disturbance 
of Nutrition — Glycosuric Urine — Tests for Glycose — Heller's Process— Boetger's 
Process — Trommer's Process — Dosage of Glycose — Duhomme's Method — Prognosis of 
Diabetes — The Diabetes of Fatty People — The Diabetes of the Lean — Grave Diabetes — 
Diabetes of Medium Intensity — The Mild Form — Hygiene of the Diabetic — Alimentary 
Hygiene — Bases of the Alimentation of the Diabetic — Regime of Cantani — Regime of Bou- 
chardat — Regime of Seegen — Gluten Bread — Soups — Legumes — Fruits — Pastries — Alco- 
holic Beverages — Beverages in General — Glycerine-Resume of the Alimentary Hygiene — 
Exercise — Results of Treatment — Pharmaceutical Treatment — Anti-fermentescible Med- 
icaments — Lactic Acid — Narcotics — Valerian — Ergot of Rye — Iodine and the Iodides — 
Alkalies — Their Action in Glycosuria — Arsenic — Bromide of Potassium — Thermal Treat- 
ment of Diabetes — Electricity — Hydrotherapy — Local Treatment of Diabetes. 

Gentlemen: Diabetes 1 is a very common affection, which you will often 
be called upon to treat when you shall have entered upon your practice; I pro- 

1 Cantani has given a full history of diabetes, which he divides into four periods: 

The first, which commences with Aretseus and Galen, and during which the presence of 
sugar in the diabetic urine was recognized though ill-understood. 

The second, which commences with Willis, and in which the symptomatology of 
diabetes was accurately established. 

The third, which is associated with the name of Rollo, who, more than any of his 
predecessors, pursued a practical end while discussing, with more method than they, certain 
theories which were largely adopted. 

The fourth, which commences with Claude Bernard, and in which diabetes is studied 
by the aid of the experimental method from the standpoint of pathogeny and therapeutics at 
the same time. 

Diabetes was known from the most remote antiquity by the physicians of India, where 
it was described under the name of sweet tirine, or urine of honey. In two books translated 
from the Sanskrit, diabetes is called madume'he, which means urine of honey. 

The ancients knew little about diabetes; at the same time, Cornelius Celsus mentions 
it, and Aretseus gave it the name of diabetes, from the Greek word Siaficavao, implying that 
the sweet drinks of persons so affected passed through the body unchanged. 

Galen also considered diabetes as a disease of the kidneys attended with elimination of 
sweet beverages unaltered, and these ideas were adopted by Willis. Moreover, Vittorio 
Trincavella, in support of these Galenic notions, cites a case where the urine of a diabetic 
patient had the same taste as the drinks which he imbibed. During this period Paracelsus 
alone took a stand against this theory of Galen, and affirmed that the cause of diabetes was 
in the blood, and not in the kidneys. 

In 1675 Willis detected sugar, or rather honey, in the urine, and thenceforth the symp- 
toms of this disease came to be better known. Sydenham thought that it was a disease of 
malassimilation; and Dobson proved, by the fermentation test, the presence of sugar not 
only in the urine, but in the blood. Lastly, Rollo inaugurated the dietetic treatment of 
diabetes, which hygienic regime has been crowned by the labors of Bouchardat dating from 
1 841; and within the present epoch Claude Bernard has given to the world his valuable 
discoveries concerning glycsemia and the glycogenic functions of the liver, (a) 



(a) Cantani on Diabetes. Paris, 1876. 

285 



286 ON THE TREATMENT OF DIABETES. 

pose, therefore, to devote a lecture to the therapeutics of this disease. So 
frequent, in fact, is this complaint that Bouchardat affirms that out of every 
twenty men between forty and sixty years of age, and pertaining to the 
wealthier classes, you are sure to meet with at least one diabetic patient. 1 

Whence comes this really large number of glycosuric patients ? It results, 
first of all, from the fact that we are better acquainted with the affection, and, 
moreover, with the conditions of modern life, which, in exciting unduly the 
digestive functions and those of the cerebro-spinal axis, predispose notably to 
this disease. There is, then, a preponderating interest in knowing the thera- 
peutic rules which ought to be observed in such cases, especially since, when 
these rules are followed, they cause disappearance of sugar from the urine, and 
all the troubles which rise from glycosuria. But before entering upon the main 
part of my subject, there are two preliminary questions which must be decided: 
the pathogeny of diabetes, and the tests which determine the presence of sugar 
in the urine. 

Pathogeny plays an important part in the therapeutics of diabetes; it con- 
stitutes setiological therapeutics, and we cannot discuss scientifically the influ- 
ence of medicaments and medications till we have examined the mechanism of 
glycosuria. Thanks to the brilliant researches of Claude Bernard — researches 
which constitute, perhaps, his best title to glory — we know to-day what is the 
origin of the sugar which is found in the normal state in the blood of animals. 2 

1 Bouchardat affirms that in every twenty men from forty to sixty years of age, 
belonging to legislative assemblies, the great learned societies, elevated positions in com- 
merce, finance, and even in the army, you are sure to find one glycosuric patient. As for 
the frequency according to age, he adds that glycosuria is the more formidable the younger 
the subject, and that the epoch when it is most often observed is between the ages of forty 
and sixty years. Griesenger's statistics . give the greatest frequency between the ages of 
twenty and forty. This is perhaps true as far as hospital practice is concerned, but it does 
not represent the frequency of this disease in private practice, and especially among persons 
in easy circumstances. Andral's table, which concerns 84 cases of diabetes, gives the 
following figures: 

AGE. CASES. 

From o to 5 years 2 

" 10 "20 " 3 

" 20 "30 " 12 

" 30 " 40 " , 20 

" 40 " 50 " 20 

" 50 "60 " ...13 

" 60**70 " 12 

" 70 " 80 " 2 (a) 

2 Claude Bernard has dwelt particularly on the origin of the glucose which is found in 
the blood. This glycaemia comes from two sources — from alimentation, and from glycogen 
formed in the liver. 

The glucose furnished by food is a product of the digestion of amylaceous matters by 
saliva and the pancreatic juice, and also of saccharine articles of diet which are transformed 
from saccharose into glucose by the action of the intestinal juice; this juice contains a 
ferment, which Claude Bernard calls inversive ferment. The role of the liver in this case is 



(a) Bouchardat, On Glycosuria and Saccharine Diabetes. 



ON THE TREATMENT OF DIABETES. 287 

This physiological glycaemia has two origins. Either it is a fact of alimen- 
tation—the feculents and cane sugar being transformed into glucose by the 
intestinal juice, the salivary disatase and by the pancreatic juice, constitute the 
first of these sources — or else it is a product of the glycogenic functions of the 
liver. Claude Bernard has, in fact, shown us that there exists in the liver an 
animal amyloid principle, glycogen, 3 and that this starchy principle, under the 
influence of an hepatic ferment, furnishes glucose. Notwithstanding the vehe- 
ment attacks which Pavy 4 and Lussana have made upon the doctrine of the 
normal glycogenic action of the liver, pretending that this sugar formation was 
simply a pathological or post-mortem phenomenon, the views of Claude 
Bernard are none the less admitted by the majority of physicians. 

Rouget, on his part, generalizing the glycogenic functions, has strongly 
maintained that all parts of the body, and particularly the muscles, possess 
glycogenic properties. But we are not obliged to enter into the discussion of 
all these objections; it suffices us to know that glycosuria, or the passage of 
sugar in the urine, is the exaggeration of a normal phenomenon, physiological 
glycsemia, that is to say, the presence of glucose in the blood. The conditions 
which, exaggerating this physiological glycsemia, transform it into a persistent 
glycosuria, are numerous; and, according as they have been exclusively adopted 
to explain the mechanism of diabetes, a great many theories have been pro- 
posed. 5 

said to be that of a reserve depot for this alimentary sugar, and to supply it to the blood in 
proportion as it is required. The glycogen or animal starch (which forms a singular explo- 
sive substance with nitric acid, takes a violet color with iodine, and passes to the state of 
dextrine) in presence of a hepatic ferment is transformed into glucose. 

Claude Bernard insists that the formation of sugar in the liver is a normal fact. The 
liver, then, is the seat of two orders of phenomena — phenomena of assimilation, and 
phenomena of disassimilation. The first correspond to the formation of glycogen, the latter 
to its transformation into dextrine and glucose. The more active the life, the more pro- 
nounced the phenomena of disassimilation. (a) 

3 Glycogen is a hydrocarbonaceous substance isomeric with starch; has for formula 
C 6 H 10 O 5 ; dissolves in water forming a milky opalescent liquid with right-handed polariza- 
tion. Under the influence of dilute mineral acids, saliva, pancreatic juice, blood serum, and 
of hepatic extract (prepared cold), glycogen is transformed first into a variety of dextrine, 
then into glucose. This transformation demands for its production a temperature of 30° C. 
Cold nitric acid transforms it into xyloidin, and warm nitric acid into oxalic acid. 

4 Pavy maintains that the sugar produced by the liver results from a cadaveric trans- 
formation, or from pathological conditions. These pathological conditions have their source 
in the non-fixation by the liver of an excessive quantity of sugar derived from food, and we 
ought to distinguish here the amylaceous aliments and the azotized aliments. As for the 
former, we are concerned with the product of an incomplete digestion; as for the latter (the 
azotized aliments), three conditions may aid their transformation into sugar: (1) general 
venous stasis, from exaggerated muscular movements, from asphyxia, etc. ; (2) troubles in 
the portal circulation; (3) section of the filaments of the great sympathetic, disturbing the 
hepatic circulation, (b) 

5 The number of theories put forth as to the cause of diabetes is considerable. As 



(a) Claude Bernard on Diabetes and Glycogenesis, in Revue des Cours Scientifiques, 1873. 
(i>) Pavy on Diabetes, London, 1862. 1868. Also lectures in the Lancet. 



288 ON THE TREATMENT OF DIABETES. 

From the exclusive point of view on which I am placed, that is, the stand- 
point of treatment, all these theories may be referred to three heads: the 
hepatico-intestinal or alimentary theory; the nervous theory; and, lastly, the 
theory of nutritive disturbance. 

According to the first theory, the glycosuria results either from the too 
great abundance of saccharine and starchy aliments, or from an excess of 
activity of the digestive ferments, or from exaggerated action of the functions 
of the liver. In the normal and physiological state, the glucose which has been 
formed in the intestinal tube passes into the circulation, and the liver becomes 
the regulator of this normal glycaemia; when the glucose is in too great 
quantity, it stores it away; when deficient, it furnishes this principle to the 
economy, thanks to the glycogen which its cells contain. But let some circum- 
stance arise to trouble this harmony," and we pass from the physiological to the 
pathological state, and glycosuria appears. This glycosuria then entails a series 
of modifications, more or less grave, in the economy, and we soon have all the 
symptoms of the confirmed disease. This theory is one of the most seductive, 

many as fifty have been designated, but all may be referred to five principal theories, which 
are the following: 

I. The gastro-intestinal theory. 
II. The hepatic theory. 
III. The nervous theory. 

IV. Theory based on disturbance of nutrition. 
V. Pancreatic theory. 

I. The Gastro-intestinal Theory. This is the theory of Bouchardat. It is divided into 
two parts, the alimentary theory and the digestive theory. In the first, the sugar of diabetic 
patients comes from a dietary overcharged with feculent and saccharine matters; in the 
second, the habitual action of the ferments of the digestive tube is too energetic. 

II. Hepatic Theory. This theory is supported by Claude Bernard. The cause of 
diabetes consists in a circulatory trouble, in a secretory trouble, or in a simple exaggeration 
of the function of the liver. It is supported by clinical observations in which diabetes has 
been observed to arise from hepatic derangements, such as congestions, or even cirrhosis. 

III. The Nervous Theory. This theory is based on physiological, anatomical, setio- 
logical phenomena, Patho-anatomical observations have found, in diabetic patients, lesions 
of the floor of the fourth ventricle, congestion, ramollissement, sclerosis of the spinal cord 
and of the brain, alterations more or less profound of the great sympathetic. From an aetio- 
logical standpoint, contusions of the encephalon and excesses in the functionating of the 
nervous system have produced diabetes. 

IV. Theory of Nutritive Troubles. This is the theory which has recently received the 
support of Bouchard. The glycaemia of diabetes depends on a fault in the consumption of 
sugar by the tissues, due to a diminution of their nutritive activity. The cause of this 
retardation is a vicious habit, congenital or acquired. Gout and a sedentary life are the most 
important factors in diabetes. Jaccoud also admits that the cause of this disease is an altera- 
tion of nutrition, over-production or lessened destruction of sugar. 

V. Pancreatic Theory. This theory is based exclusively on pathological anatomy. 
Lancereaux is its chief supporter. Diabetes is due to lesions of the pancreas, such as 
atrophy, fatty degeneration, cancer, obliteration of the pancreatic duct. 

6 Colrat and Couturier, taking as their basis certain experiments of Claude Bernard — 
who showed that when the portal vein is tied the glucose passes directly into the blood, and 
produces an alimentary glycosuria — have noted that, in animals affected with total or partial 
obstruction of the portal vein, from any cause whatever, glycosuria always exists. 



ON THE TREATMENT OF DIABETES. 289 

and has for its consequence therapeutic applications which dominate in the 
treatment of diabetes, I refer to the alimentary regime. My venerated master, 
Bouchardat, has won the claim to public gratitude by founding, on this theory, 
that admirable hygienic treatment which enables us, through its rigorous appli- 
cation alone, to cause the sugar to disappear from the urine of diabetic patients, 
at least in the great majority of cases; and when this hygienic treatment fails, 
be assured that the disease will almost invariably resist all other therapeutic 
means. 

The nervous theory is also based on experimentation, 1 on clmical experi- 
ence, and on the results of therapeutics. We know, in fact, since the celebrated 
experimentation of Claude Bernard, that we can in animals cause a temporary 
glycosuria by irritating or wounding the rachidian bulb. 

Schiff, by traumatic lesions of the entire cerebro-spinal axis, and even of 
the sciatic nerve, Pavy, Eckhard, Cyon, Aladoff, by traumatisms of the ganglia 
and filaments of the great sympathetic, have arrived at the same result, and 
have in this way determined a glycosuria equally transient. 

I insist on the word transient, for it shows us that, unable to produce true 
diabetes in animals, we cannot practise on this disease experimental therapeu- 
tics, for the glycosuria which results from our experiments gets well of itself in 
the course of several days. 

In support of the nervous theory of diabetes, clinical medicine furnishes a 
great number of observations where we see violent blows on the head, or great 
cerebral excitation, the consequence of too prolonged intellectual labors, painful 
emotions, chagrin and disappointment, become the starting-point of diabetes. 
This it is which explains why this disease is so common among certain classes 
of the population, such as literary men and persons devoted to scientific and 
academical pursuits. You will not, then, be astonished to see a considerable 
number of authorities claiming that diabetes is always of nervous origin. 

As for that theory which refers diabetes to disorders of nutrition, it has 
been quite recently defended, and with considerable success, by Professor 
Bouchard, 2 who has classed diabetes with affections due to retardation of 

1 Claude Bernard showed, in 1849, that pricking or puncture of the fourth ventricle 
below the origin of the vagi causes glycosuria. Section of the splanchnics after the puncture 
does not modify the glycosuria, but it prevents it when made before the puncture. 

Schiff produced glycosuria by section of the optic thalami, crura cerebri, pons, middle 
and posterior peduncles of the cerebellum, also by section of the spinal cord on a level with 
the second dorsal vertebra, by extensive lesions of the anterior and posterior columns, and 
even by section of the great sciatic nerve. Richter has shown that lesions of the sympathetic 
have the same effect; Pavy, that section of the superior cervical ganglion occasions glyco- 
suria. Eckhard, Cyon and Aladoff have attained similar results with sections of the inferior 
cervical and superior thoracic ganglia, (a) 

2 Bouchard shows the difference which exists between arterial and venous blood a 
propos of sugar. In animals this is 40 centigrammes; that is, one kilogramme of arterial 
blood in becoming venous blood loses 40 centigrammes of sugar. When you take into 



(a) Schiff, Jour. d'Anat et de Physiol., 1866. CI. Bernard, Arch. gen. de Mec, 1849. Bouchard, Mala- 
dies par Relentissement de la Nutrition, Paris, 1882. 
§19 



290 ON THE TREATMENT OF DIABETES. 

nutrition. Here also we can deduce facts in support of this theory from physio- 
logical and clinical experimentation. The glycogenic function is not, in fact, 
exclusively a function of the liver; all the tissues participate in it. Have we 
not seen Rouget demonstrate this power of sugar-production in all organs of 
the foetus ? Have we not seen Schiele detect glycogen in stratified pavement 
epithelium ? In fine, do not the muscles themselves participate in this glyco- 
genic function, as Boehm 3 has pointed out ? We can, then, say, with Bouchar- 
dat, Jaccoud and Bouchard, that every circumstance which troubles the inmost 
processes of assimilation and of disassimilation of all the tissues maybe a cause 
of diabetes. 

One other consequence of this theory is to call attention to the elimination 
of urea in diabetic patients, and to cause this azoturia to play a preponderant 
part as Lecorche has done. 

Ought we to take sides with one or the other of these theories, and base 
exclusively on any one of them our therapeutic endeavors ? By no means ; and 
we ought instead to draw from all them the elements of our treatment. But I 
must, before approaching this main subject of my lecture, set forth the clinical 
means which you ought to make use of in order to determine the presence of 
sugar in the urine, and the quantity of this abnormal ingredient. 

You should, in fact, be aware that we cannot judge of the effects of our 
treatment but by a daily examination of the urine ; our prognosis, moreover, 
is based on such examination ; you should then perfectly understand the modes 
of testing urine for glucose. 

Glycosuric urine is generally abundant in quantity, of a high density, 
which sometimes attains even 1050 ; it is frothy, stains the clothing, and has 
the curious property of attracting flies. 

To detect glucose in the urine we avail ourselves of the curious oxidizing 
and reducing property of this substance in presence of alkaline agents, and 
without stopping to consider the numerous processes which have been proposed 



consideration the total quantity of blood which is transformed into venous blood, it is suscep- 
tible of demonstration that a man loses in a day, at the least, 1,850 grammes of sugar; now 
one gramme of sugar demands, for conversion into water and carbonic acid, 1 gr,, 066 of 
oxygen, and as a man in health never consumes more than 850 grammes of oxygen a day, 
this oxygen is incapable of burning all the sugar; there remains, then somewhat more 
than 1,000 grammes of sugar which is not consumed by oxygen, but which is destroyed by 
molecular metamorphoses of the entire organism. So, according to Bouchard, the condi- 
tions which give rise to hyperglycsemia may be referred to the following heads : (1) every- 
thing which prevents the sugar and starch of food ingested from fixing itself in the liver in 
the state of glycogen; (2) everything which increases the formation of sugar in the liver; 
(3) everything which interferes with the destructive metamorphosis of sugar in the economy 
or its fixation in the tissues, (a) 

3 According to Boehm, the muscles behave with regard to glycogen like the liver; that 
is to say, glycogen augments in the muscular tissue after meals, and is destroyed in 
muscular work. 



(a) Bouchard, Maladies par Ralentissement de la Nutrition. Paris, 



ON THE TREATMENT OF DIABETES. 291 

by Krause, 1 Luton, Muller, 2 Maumene, 3 Neubauer, and Vogel,* will mention 
only those of Heller, Boettger, and Trommer. 

The first of these processes is based on the oxidation of glucose by potassa, 
which by heat generates glucic and melassic acids which give to the liquid 
under examination a more or less black color according to the quantity of sugar 
in solution. Bouchardat has substituted for the potassa a chemical which is 
much more easy obtainable, slaked lime or milk of lime. 6 This test, which is a 
good one when the urine has a large amount of sugar, loses its value when the 
quantity of glucose is small ; then there is liability to several sources of error ; 
the coloring matter of the urine, for instance, may turn brown under the agency 
of alkalies. Moreover, albumen and mucus may give a dark discoloration, and 
even an impure preparation of potassa may give the same color. 

The process of Boettger is altogether different ; it consists in heating urine 
supposed to contain glucose with a mixture of subnitrate of bismuth and car- 
bonate of soda ; in this white liquid thus formed there is soon seen a black pre- 
cipitate of oxide of bismuth. 6 Although this test has been modified by my 
master, Behier, and more recently by Primavera, it is subject to numerous 
fallacies, and the reduction of bismuth may be accomplished by substances 
other than glucose. Attfield affirms that almost any kind of urine will effect 
the reduction of bismuth. Therefore this test is inferior to those which have 
for basis the cupro-alkaline liquors. 

Trommer was the first to recommend testing for sugar in urine by util- 
izing the reducing properties of glucose on salts of copper, and it is upon this 

1 Krause and Luton employ the same test as for the detection of alcohol, namely the 
solution of bichromate of potash in sulphuric acid ; this solution, of an intense red color, be- 
comes emerald green in the presence of sugar. 

2 Muller uses the following test: To the urine heated over a spirit lamp he adds a solu- 
tion of indigo-carmine made alkaline by bicarbonate of soda. If glucose be present this 
mixture passes from blue to green, then red, purple, and finally yellow. Jaccoud recom- 
mends this process. 

3 In Maumene's process, strips of woolen cloth are soaked in a solution of perchloride 
of tin ; then moistened with the urine to be examined and heated over a spirit lamp. If 
sugar be present the strips are blackened. 

4 This test consists in adding to urine supposed to contain sugar, a few drops of solu- 
tion of ammonio-nitrate of silver ; if glucose be present there is a black precipitate of 
reduced silver. 

5 Saccharine urine when mixed with an equal volume of liquor potassa and heated, 
turns yellow, and, if sugar be abundant, brown; a molasses-like odor is at the same time 
observable. 

[ 6 Boettger's test, which is much in use in this country, is practiced in the following 
manner : A few cubic centimetres of the urine are mixed in a test tube with an equal volume 
of solution of sodium carbonate (one part crystallized carbonate and three parts water) a few 
granules of bismuth subnitrate are added, and the mixture boiled for some time. If sugar be 
present the bismuth turns brown or black by reduction to elementary bismuth. (Witthaus' 
General Medical Chemistry.) Witthaus affirms that no other normal constituent of the 
urine reacts with this test, but there may be some substance present which, by giving up 
sulphur, may cause the formation of a black sulphide of bismuth. — Trans.] 



292 ON THE TREATMENT OF DIABETES. 

basis that a number of test liquids have been devised, Barreswil's and Fehling's 
solutions for instance. 1 

Fehling's solution is the most used at the present day ; the reaction is very- 
pronounced, and it suffices to heat in a test tube a mixture of glycosuric urine 
with one of those cupro-alkaline solutions to see the liquid change from a 
beautiful blue to a pale yellow, then a lively red, in consequence of the precipi- 
tation of the oxide of copper, which gradually settles down to the lower part of 
the test tube. 

At the same time with this method, which is much the most certain, all 
chances of error are not avoided. Uric acid, urinary pigment, tyrosin, may 
cause the precipitation of oxide of copper, but this precipitation is much less 
clear and pronounced than that with glucose. Moreover, albumen prevents 
this reaction from taking place, therefore it will be necessary to have care when 
you are examining urine that contains both albumen and sugar (which fre- 
quently happens) first to precipitate and filter out the albumen before proceed- 
ing to test for sugar. 

The employment of the cupro-sodic liquors enables us not only to recog- 
nize the presence of sugar, but also to determine the quantity, and this is a 
matter of great importance. I shall not here speak of the polarimetric processes 
while admitting that they are the most sure and precise, and that one ought 
always to have recourse to them when desirous of attaining mathematical exact- 
ness in the dosage of glucose, but these are methods of the laboratory, and few 
physicians can have at their disposal a saccharimeter, whether it be that of 
Soleil, or the one with a penumbra, or the diabetometer of Yvon. I shall only 
mention the clinical processes which are quite sufficient in practice. 

Of all the clinical processes the most simple, the most ready, and the most 

1 There are several formulae for cupro-potassic or cupro-sodic solutions. These are 
the principal : 

SOLUTION OF BARRESWIL. 

I£. Carbonate of soda 4 grammes. 

Cream of tartar 5 grammes. 

Caustic potash 4 grammes. 

Water 40 grammes. M. 

Add. Sulphate of copper 3 grammes. 

Water 25 grammes. M. 

fehling's solution. 

Take the pure Sulphate of copper 4 grammes. 

Distilled water 16 grammes. 

Caustic soda 13 grammes. 

Neutral tartrate of potas 16 grammes. 

Distilled water 60 grammes. M. 

Trommer's test, the first in use, is employed as follows : Take a sufficient quantity of 
liquor potassse and a solution of sulphate of copper. Into a certain amount of urine in a test 
tube add an equal quantity of liquor potassae and two or three drops of the solution of cupric 
sulphate. If the urine contains sugar the blue mixture with hydrate of copper clears up by 
agitation, and if the tube is heated a precipitate of reddish cupric oxide is formed. 



ON THE TREATMENT OF DIABETES. 293 

economical is that of Duhomme,' which we use every day in the hospital and 
in private practice, and every physician, it might almost be said every diabetic 
patient, ought to have one of these little instruments for measuring the amount 
of sugar in the urine. 

It is composed of a little box which has in its interior some test tubes, a 
spirit lamp, two vials, the one containing a little liquor sodse, the other Feh- 
ling's solution, and finally, two dropping tubes. 2 These two dropping tubes 
are graduated, the one which is reserved for urine by a mark which indicates a 
cubic centimetre, the other, which is destined to contain Fehling's solution, by 
a mark which measures just two cubic centimetres. You begin by taking up 
one cubic centimetre of urine of which you take care first to count the number 
of drops by pressure on the rubber ball. Then with the other dropper you 
aspirate two cubic centimetres of Fehling's solution. This you place in a test 
tube, and add the same quantity of solution of soda. You then heat the mix- 
ture, and after having taken up some of the urine of which you have just 
counted the drops, you let it fall, drop after drop, into your test liquid, heating 
the latter from time to time till the entire mixture takes on a reddish color. 
You have counted the number of drops necessary to obtain this reaction, and 
you have only to refer to the table herewith given (see adjoining page) to know 
the quantity of sugar contained in a litre of the urine. This table contains in 
one column the number of drops present in one cubic centimetre of urine, and 
in another the number of drops made use of in order to get the characteristic 
color. 

As this method of analysis is very rapid it is desirable, before taking a 
definite figure, to repeat the process three or four times, in order to know 
exactly the number of drops necessary to obtain the red color in the mixture. 

It may be necessary when the percentage of sugar is very large to dilute 
the urine with an equal quantity of water, which you can easily do by means of 
your dropper, and in estimating the result you have simply to double the figure 
obtained. Duhomme has, moreover, given a method for utilizing his sacchari- 
meter for the detection of very feeble quantities of sugar. It suffices in these 
cases to employ only one cubic centimetre of Fehling's solution, and to count 
the number of drops necessary to effect the disappearance of the green color 
you can make use of the same table, but you must carry the decimal point one 
line toward the left. 

With this analytical process you can sufficiently estimate the effects of your 
treatment. You will also have a basis for your prognosis. You are aware that 
there are two kinds of diabetes. The one is the mild form, diabetes benignus, the 
diabetes of fat people, an affection which permits a person to live a good many 

1 Duhomme, Clinical Saccharimetry, Bull, de Ther., t. lxxxviii, 1875, pp. 163, 214, 
and 261. 

[ 2 The dropping tubes graduated to indicate cubic centimetres can easily be obtained of 
instrument makers, Codman and Shurtleff of Boston, for instance. 

The method of Duhomme is so handy and simple that it ought to come into general 
use ; it is, in fact, in general use on the Continent. Besides the dropping tubes and the 
printed table all that is required is the ordinary cupro-sodic testing solutions. — Trans.] 



294 



ON THE TREATMENT OF DIABETES. 



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ON THE TREATMENT OF DIABETES. 295 

years. The other is grave diabetes, the diabetes of lean people, which disturbs 
profoundly the nutrition of the individual, and determines in quite a short 
space of time cutaneous, pulmonary, or other complications which rapidly prove 
fatal. 

There has been much discussion as to whether we ought to give the name 
diabetes to both these affections, some maintaining that the diabetes of the cor- 
pulent is nothing but a symptomatic glycosuria, and reserving the name dia- 
betes to the more malignant disorder of lean people ; others hold that the two 
affections are the same, but of different degrees of intensity. 

Without entering into the discussion I can affirm that from a therapeutic 
point of view the examination of the urine will enable you to class your patients 
in three principal groups : the light forms of diabetes, those of medium inten- 
sity, the grave forms. Note first of all that the quantity of sugar which you 
find is no criterion for prognosis ; you may find as much as one hundred 
grammes per litre, and at the same time have a very mild case. A much more 
important indication is the persistence of a certain quantity of sugar in the urine 
in spite of the most rigid dietetic regime. 

When, after having made your patient follow scrupulously a rigorous ali- 
mentary regimen, you discover that the figure of sugar in the urine keeps at 
from thirty to fifty grammes per litre, be persuaded that your case is a grave 
one, and that your pharmaceutical measures, however judicious and appropri- 
ate, will not stay the progressive decadence of the organism and the death of 
your patient. Generally these patients are thin, debilitated, presenting pulmon- 
ary complications of a tuberculous nature, and their forces are rapidly 
exhausted. I have often been called during my medical career to treat such 
diabetic patients, and despite all my endeavors have not been able for an instant 
to interrupt the steady decline of the organism. 

When, on the other hand, the quantity of sugar, owing to your alimentary 
hygiene, has fallen to nine or ten grammes a day, you have a case of diabetes 
of medium intensity. These are the patients who may live many years, but in 
whom there supervene, when the digestive functions become enfeebled, pulmon- 
ary complications, a peculiar comatose state, or it may be cerebral ramollisse- 
ment, an accident so frequent in those whom Bouchardat calls petits diabetiques 
(that is, persons slightly diabetic). These diabetic patients are amenable to a 
treatment which opposes to a certain extent the production of such accidents. 

In the third group are cases of diabetes of feeble intensity. Here we witness 
the triumph of alimentary hygiene, for it alone effects very rapidly and in a few 
days the disappearance of the glucose from the urine, however great the pre- 
vious quantity. How often have I seen such obese patients, generally arthritic 
and gouty, who had been voiding two hundred to three hundred grammes of 
sugar per day, and in whom the regime of Bouchardat had enabled us in a few 
days to bring down the figure to zero. Nevertheless in these patients the sugar 
reappears whenever they commit errors in diet. 

You see, then, that this dosage of sugar, or, in other words, the determina- 
tion of the quantity of sugar in urine, is a matter of capital importance to your 
patients both from the point of view of therapeutics and of prognosis, and I 



296 ON THE TREATMENT OF DIABETES. 

pass now to the consideration of the hygienic and medicinal means applicable 
to the treatment of diabetes. 

The dietetic treatment of diabetes deserves the first place. Ever since John 
Rollo, at the end of the last century, first called attention to the influence of 
foods in the production of glycosuria, all authorities have felt the obligation to 
regulate rigorously the diet of diabetic patients. At their head is Bouchardat; 
after him I will mention especially Seegen, a German writer, and Cantani, an 
Italian, and what I have now to offer respecting the hygienic regime of this 
affection will be based on a careful study of the contributions of these three 
men. 1 

The hygienic treatment is founded on the endeavor, as far as possible, to 
exclude from the food all substances capable of forming glucose. This glucose 
may be derived from sugar in the ingesta, or from starch which has undergone 
conversion in the alimentary canal. These glycogenous principles, then, 
should be suppressed. All this, however, though simple in theory, is difficult 
in practice. 

I told you in a former lecture, when on the subject of Digestion, that an 
adult man loses by day 20 grammes of nitrogen and 310 grammes of carbon, 
and that in order to avoid emaciation he must obtain in his food this quantity of 
nitrogen and carbon; it is well always to have these figures before you when 
you wish to lay down dietetic rules for your diabetic patients. The 310 
grammes of carbon are furnished by sweets, feculents and fats, and the sup- 
pression of the' first two of these alimentary substances must considerably 
modify the conditions of alimentation. For, in order to suffice for this com- 
bustion of 310 grammes of carbon, if a man eats nothing but meat, he must 
consume two kilogrammes, so that a diabetic patient confined to a diet exclu- 
sively of animal food must be made to eat about four pounds a day ! This 
enormous amount of meat is not without its inconveniences; by the quantity of 
nitrogenous material not utilized it augments waste-production, and provokes 
lithaemia; it moreover fatigues unduly the functions of certain portions of the 
digestive tube. 2 

Therefore Cantani, while suppressing entirely sugar and starch, has replaced 
these principles by fat, establishing thus what he calls adipo-albuminous diet; 
but as sometimes these oleaginous substances, which ought to be absorbed in 
great quantity, are of difficult digestion for certain stomachs, he first submits 

1 Rollo, on Diabetes Mellitus, London, 1790. Seegen, on the Diet Cure of Diabetes 
(Wien. med. Woch., 1873). Bouchardat, du Diabete-Sucre, Paris, 1875. Cantani, on the 
Diet Treatment of Diabetes, 1876. 

2 Bloch has studied the action of regime on diabetic patients. He has shown that 
animal food is capable of diminishing the proportion of sugar in the urine without causing it to 
disappear; fasting has the same effect; and, moreover, the absorption of fats is very active 
in diabetic patients. So, according to him, a flesh diet, while causing sugar to disappear, 
hastens denutrition. (a) 



(a) Bloch, Absorption of Fats in Diabetes, etc., Deut. Arch. f. Klin. Medicin, Bd. xxv., Hft. 4 and 5, p. 
470, 1880. 



ON THE TREATMENT OF DIABETES. 297 

them artificially to the action of the pancreas, and administers to his patients 
panci-eatized fats. 

The regime of Cantani is difficult to follow in all its rigor; there are so few 
who can for a series of months subsist on meat and fat alone, for Cantani aims 
to have this adipo-albuminous diet continued till the complete disappearance of 
sugar from the urine. 1 

1 This is the alimentary regime of Cantani : 

Broths. Made with any sort of meat. 

Beef. Muscle, brains, tongue, etc. 

Veal. The muscle, all the internal organs, brain, sweet-bread, lungs, kidneys, but not 
the liver. 

Mutton. The same as above. 

Fowl and game of all kinds. Fish, frogs, and crustaceans. 

Salt or canned meats or fish, but in moderation. 

All the above may be either boiled, roasted, broiled, or fried in fat, and salted to the 
taste. They may be seasoned, but no sugar or starch must enter into the composition of 
the seasoning ingredients; also no wine, vinegar, butter, or lime juice. Olive oil and ani- 
mal fats may be used freely, and dilute acetic acid may be substituted for vinegar, and citric 
acid for lime juice. 

The quantity of food should be about 600 grammes a day, of cooked meat, and more if 
the scales show that the patient continues to emaciate. 

In cases where denutrition is very pronounced, in very lean patients, 60 to 200 grammes 
of pancreatized fat are given daily; this is prepared as follows: Cut into small pieces the 
fresh pancreas of a beef creature or sheep, intimately blend with it a small quantity of fat, 
and leave it for three hours or so submitted to this artificial digestion, then cook slightly. 

Drinks. Water, pure, or artificial seltzer water, to which from 10 to 30 grammes 
daily of rectified spirits may be added, and some aromatic waters (fennel, canella, balm, 
mint, orange) if desired. 

If, after a month's trial, this regime does not cause the glycosuria to disappear, it will 
be best to make the patient fast 24 hours, taking nothing but water and some rich broth. 
Then the above regimen is resumed, but in half the quantity; little by little it is increased till 
the normal quantity is attained. But if the glycosuria reappears, another day of fasting, 
then the half diet again ; which is not to be increased, unless the scales show that the patient 
is losing flesh. 

In very recent cases, or cases of little gravity, eggs may be permitted, the liver of ani- 
mals, cod-liver oil (two to four ounces a day), and shell fishes, such as oysters, snails, and 
clams. A little old red wine (Bordeaux wine is the best), a little tea or coffee without sugar. 

Exercise in the open air, gymnastics, muscular labor; this regime should be rigorously 
persisted in for two months at least in light and recent cases; for three, six, and even nine 
months in the severer cases. 

The return to saccharine and amylaceous articles of diet should be gradual, in accord- 
ance with the indications given below. 

The following aliments may be permitted to a diabetic patient who for two months at 
least has had no sugar in his urine: 

Gradual return to a ?nixed diet. Spinach, chiccory, endives, water-cresses, lettuce, dan- 
delion, corn salad, olives, etc. 

A little later. Chards, white beets, celery, artichokes, leeks, truffles, mushrooms. 

A month after. Sweet almonds, nuts, pistachios, a little red wine. 

Still later. Gooseberries, peaches, apples, and other fresh ripe fruits, fresh cheese, 
butter, etc. Little by little vegetables abounding in starch, such as potatoes, are allowed. 

During the entire duration of this return to a mixed diet the quantity of these permitted 
aliments to be very moderate, and, on the least reappearance of glycosuria, the meat regime 



298 ON THE TREATMENT OF DIABETES. 

Hence the dietetic regime of Bouchardat 2 is more generally adopted; the 
principal characteristics of this alimentary system consists in the substitution of 
gluten for starch, and in the employ of gluten-bread. 3 

This question of bread is of great importance. Habituated from their in- 
fancy to this sort of aliment, bread is to some persons quite indispensable, so 
that it is hardly possible for them to make a meal without it. This with our 
diabetic patients is a feeling which ought to be overcome. Insufficient alimen- 
tation is with these patients one of the gravest evils. You may by severe diet- 
restrictions cause sugar to disappear from the urine, but it is at the expense of 
the well-being of the entire organism. So your efforts ought to be directed 
toward instituting a regimen which, while excluding starchy and saccharine ele- 
ments, may satisfy in a certain measure the taste and appetite of your patients. 

Gluten bread and gluten cakes have been given to diabetic persons. Un- 
happily the mode of preparation of this kind of bread is not always what it 

must be resumed in all its rigor. As for cane sugar, it must be absolutely prohibited at all 
all times, (a) 

2 These are the general precepts of Bouchardat concerning the dietary of glycosuric 
persons: 

Eat moderately and slowly; food should be well masticated. 

As long as the quantity of urine passed in 24 hours exceeds a quart and a half, drink as 
little as possible. 

Eat sparingly of liquid food, such as soups, broth, consomme; take your drink in sips: 
the sensation of thirst can sometimes be alleviated by simply rinsing the mouth with ice- 
water; if ice-water is drank, let it be taken only in sips. 

Combat the sensation of thirst by chewing parched corn, roasted coffee, or olives. 

Two meals a day are preferable to three; let the one be at 10:00 a. m., the other at 6:00 
p m. Eschew repose, and especially sleep after meals; a good long walk after the repast is 
beneficial. 

Never lie down for four or five hours after the last meal. 

Abstain as far as possible from the use of tobacco. 

As for aliments, avoid feculents and sugars. 

Abstain from bread of cereals, pastries, rice, maize, potatoes, arrow-root, sago, tapioca; 
the starchy parts of all vegetables; peas, beans, lentils, nuts of all kinds, radishes, turnips, 
carrots, squashes, all kinds of fruit, and especially the saccharine fruits, such as prunes, 
grapes, figs, bananas, pears, apples, melons, should be interdicted; the same may be said 
of preserves of all sorts and all acidulated or saccharine drinks. 

Wheaten or rice flour should not be employed as an ingredient of gravies and sauces; 
but gluten flour, yolks of eggs, butter or cream should be used instead, (b) 

3 It was in 1841 that Bouchardat first called attention to gluten-bread. To obtain glu- 
ten the flour is first washed for some time (20 minutes to several hours, according to the 
purity of the flour) in a metallic sieve, No. 120. A paste is first made, and it is this paste 
which is submitted to constant irrigation. The fresh gluten thus obtained equals about one 
fourth the weight of the meal employed. The gluten should be used fresh and made into 
bread or cakes for glycosuric patients. 

Boussingault and Mayet on analyzing the gluten cakes and this flour have shown that 
they still contain a considerable proportion of starch; from 16 to 44 per cent. 

Bran bread has been highly extolled by Camplin in the treatment of diabetes. (Camp- 



(a) Cantani, Du Diabete et de son Traitement, traduction Charvet. 
{b) Bouchardat, Treatise on Saccharine Diabetes, Paris, 1875. 



ON THE TREATMENT OF DIABETES. 299 

should be, and when these culinary products have been analyzed, as they have 
been recently by Boussingault and Mayet,it is seen that they contain from ten to 
40 per cent, of starch. Therefore there has been a disposition to substitute for 
bread of gluten badly prepared, bran bread, as recommended by Camplin, or 
bread or biscuits of sweet almonds, as Kronser and Pavy have advised, or bread 
made of parched flour after Dannecy's formula, or the bread which Dahmen 
counsels. 

You would do well, gentlemen, to use all these products, as well as the 
crust of ordinary bread and stale bread, for it is not so much the amount of 
starch and sugar contained in bread that is to be taken into account as the 
quantity which the patient eats. The dry gluten bread recommended by 
Bouchardat and the almond cakes and the bran cakes being generally hard and 
firm, the patient, whose gums are almost always affected with that diabetic gin- 
givitis which loosens the teeth, is able to eat but a small quantity, and this is the 
reason why I prefer bread crust or hard, stale bread, for the patient can eat but 
a little of it. Add, moreover, that gluten bread is much less agreeable to the 
palate than ordinary bread, and that this circumstance contributes to minimize 
the quantity of this kind of food taken with meals. 

Pastries ought absolutely to be prohibited. Do not forget, in referring to 
the intersting analyses of Boussingault and Mayet, that there is an alimentary 
preparation, e'chaude or simnel, which has as much starch as ordinary bread (the 
first containing fifty-three and the second fifty-five per cent.), and this should 
be proscribed. Other kinds, as brioche, may be permitted as including no 
more starch than the gluten biscuits, or about forty per cent. 

These same analyses enable us to establish a diabetic regime from the point 
of view of feculents; potatoes, turnips, and rice contain relatively a small pro- 
portion of sugar (seven to eight per cent.), while gluten bread has 27.70 per 
cent.; hence the former are less objectionable in this respect than the latter. 
But I repeat, all depends on the quantity of these aliments taken by the patient. 
If the diabetic eats largely of potatoes, notwithstanding the small quantity of 



lin, on Diabetes and its treatment, London, 1864.) This is his recipe for bran cakes: Take 
three ounces of wheat bran, three fresh eggs, two ounces of butter, one pint of milk, stir 
well together, and flavor with nutmeg or ginger. Place this dough in hot cast-iron baking 
pans, well buttered, and put in an oven for half an hour. Eat these biscuits instead of ordi- 
nary bread. 

Pavy's bread of sweet almonds is made by first treating the almonds, reduced to fine 
powder, with boiling water slightly acidulated with tartaric acid, which deprives them of six 
per cent, of sugar. Of the paste thus obtained biscuits are made. 

Dahmen's bread is made as follows: Soak wheaten groats half an hour in cold water; 
knead the dough thus formed in a stream of cold water, desiccate the glutinous residue, and 
triturate in a mortar. Take 165 grammes of this powder, mix thoroughly with one third 
quart of sour milk, add 125 grammes of melted butter, ten eggs, a little salt, and some car- 
bonate of ammonia. When this mixture has acquired a pasty consistency place in French 
roll pans, well buttered, and consign to a hot oven till well cooked, (a) 



(a) Berlin, klin. Woch., September, 18 o. 



300 ON THE TREATMENT OF DIABETES. 

sugar in them, he will obtain the same amount of sugar as if he were to eat 
sparingly of gluten bread. 1 

As for soups, I would advise you to keep clear of those made with gluten 
grains, as well as all rich broths. Here Boussingault has given us interest- 
ing facts showing that there is a large percentage of feculent matter in these 
soups. 

As for green vegetables, I think that they may safely form a part of the 
dietary of diabetic patients, and in this opinion I am supported by Bouchardat. 
Water-cresses maybe freely indulged at meals, also dandelion greens, artichokes, 
spinach, celery, cooked salads, etc. I know that green vegetables include nota- 
ble quantities of saccharine matters, but they contain also potash, which is good 
for diabetic patients. 

As for fruits, you should be very chary in their employ. The analyses of 
Mayet are very conclusive in this regard. Nevertheless, melons, raspberries, 
gooseberries, and even oranges may be permitted under certain restrictions. 2 

As for alcoholic beverages, there are certain which are permitted, and 
others which are forbidden. Champagne, malt beer, and ale are interdicted; 
the same may be said of the effervescent, non-intoxicating drinks, lemonade, 
ginger beer, etc. Bordeaux and Bourgogne wines may, however, be allowed, 
as well as coffee and tea without sugar. 

But you must avoid the deleterious effects of alcohol on the economy. A 
great many diabetics, to satisfy their intense thirst, drink great quantities of 
wine and other alcoholic preparations. Such excesses are very detrimental. 
Bouchardat would limit diabetic patients to one quart of wine a day. 

1 Amount of sugar in ioo grammes: 

Turnips 7.00. Lentils cooked and drained 22.50. 

Baked potatoes 8 . 30 . Rice cake 25 . 00 . 

Rice (cooked in water) 8 . 00 . Fresh gluten bread 27 . 70 . 

Peas (boiled) 12.00. Lancry's gluten bread 3I.I5* 

Pea soup 15 60. Bread of the Vichy Company 31.00. 

Beans 16.00. Ordinary bread 60.00. 

Carrots 16.60. Ordinary flour 71.00. 

Chestnuts 20 . 00 . Ordinary starch 83 . 00 . 

2 The analysis of Boussingault shows that cabbages, chiccory, turnips, carrots, beets, 
potatoes, and spinach contain from two to four per cent, of potassa. 

The analysis of Mayet shows that the following fruits contain the per centage of glucose 
herewith given: 

In 100 grammes. In 100 grammes. 

Gooseberries 1.50 to 8.00. Peaches 10.50. 

Melons 7. 50. Figs 15.00. 

Raspberries 1 to 8.00. Prunes 16.00. 

Oranges 10.00. Dried prunes 42.00. 

Cherries 10.25 . Dried figs 71.00. 

Dried raisins 76 . 00 . (a) 



(a) Mayet, Note on Sweet Fruits from the Point of View of their Introduction into the Dietary of Dia- 
betics, Union Med., 1873. 



ON THE TREATMENT OF DIABETES. 301 

This subject of drinks is a very important one, for it is a pressing 
indication to diminish the excessive thirst which plagues diabetic patients, 
and many of them will keep demanding of you what they shall drink. I 
am much in the habit of ordering Vichy water, or water holding in solution 
from five to ten grammes of Seidlitz salts, or even mild bitter infusions, as of 
cinchona, hops, quassia, camomile, but it is well to urge the patient not to yield 
to his thirst, but to combat it as far as possible. 

Apropos of these beverages I ought to mention the employment of glycer- 
ine 1 in the treatment of diabetes. This triatomic alcohol gives good results 
in this disease, if we may trust to the experience of Schultzen, Harnach, and 
Holtz. In fact in the case of those patients who cannot tolerate the entire 
suppression of sugar in their drinks glycerine may sufficiently replace it, but 
it is necessary to protest against the large doses which have been recom- 
mended, but we have demonstrated (Audige and myself) that glycerine 
may become toxic, (a) 

Therefore, to recapitulate, these are the rules on which you should found 
the alimentation of diabetic patients; total abstinence from sugar and from 
sweetened food; diminution as complete as possible of amylaceous substances; 
animal food and fresh herbs, care being taken to select such vegetables and 
such feculent articles as have the least quantity of saccharine matters; almost 
entire abstinence from bread; Bordeaux wine, bitter drinks; no distilled liquors 
nor sweetened beverages. 

The diabetic invalid, habituated to good cheer, or ordinarily a high liver, 
will ask of you not only general indications but also particular details respecting 
the maniier of varying his daily bill of fare. You will be able to satisfy this 
demand by consulting the "menus" of Bouchardat, that I place in part before 
you, 2 and which should guide you in the choice of your culinary preparations* 

1 Schultzen, of Dorpat, has counseled the use of glycerine in diabetes, which he 
considers a powerful adjuvant to the ordinary alimentary regimen. The same may be said 
of Gamier; both give twenty to twenty-five grammes (or somewhat less than an ounce) 
daily. Harnach recommends still larger doses, from 180 to 360 grammes a day (or from six 
to twelve ounces), and affirms that these quantities have no injurious effect, have no influence 
on the amount of sugar eliminated, and rather favor the amelioration of the patient. Holtz 
believes that glycerine has not merely a neutral effect as far as the glycosuria is concerned, 
but that it decidedly lessens sugar excretion, {b) 

2 [The "menus" of Bouchardat are omitted, as being more applicable to the gourmands 
of France than of this country. In brief, soup with cabbages and leeks, without bread or 
flour, are permitted, also rich broths with gluten crackers. Meats of almost all kinds are 
allowed, with hors d'ceuvre, as before given (vide supra); eggs, shell fish, salads, and entremets 
of gluten cakes, waffles of gluten flour or pure bran, jelly with rum, kirsch, or coffee without 
sugar, omelets with rum (not sweetened), and vanilla. He also specifies as allowable, among 
the entremets, artichokes, cabbage with salad oil, griddle cakes of gluten flour, with 



(a) Dujardm-Beaumetz and Audige, on the Properties of Glycerine. (Bull. gen. de Ther., t. xci., pp. 51 
and 135.) Also, Experimental Researches on the Toxic Power of the Alcohols. Paris, 1879 

(b) Gamier, on Glycerine in the treatment of Glycosuria, Comp. Rend, de l'Acad. des Sc, 10 Mai, 1875. 
Harnach, on the Treatment of Diabetes by Glycerine, Deutsch. Arch. f. klin. Med., vol. xv., p. 449, Holtz, 
Ueber Diabetes, Petersburger. Med. Woch., No. 3, 1880. 



302 ON THE TREATMENT OF DIABETES. 

but do not forget that the rules which I have just prescribed, and which have 
been also adopted by Seegen, 3 are not absolute, and that you will be com- 
pelled in many circumstances to make compromises in the rigorous application 
of this dietetic regimen, for if it is dangerous for a diabetic to eat feculent and 
saccharine substances, it is more so to see him reject all kinds of food with 
disgust. In fact I cannot do better than to remind you of what has taken place 
in our female wards, where we had lately occupying No. i a lady patient suffer- 
ing from the grave form of diabetes, and whom we have sent to Vichy. This 
woman, much emaciated, was losing more than 400 grammes of sugar a day. 
We desired to submit her to an exclusive regimen of meat and herbs, but she 
could not make a meal without bread, and gluten bread, as well as other kinds 
of hard bread, were intolerable to her. Therefore this privation of bread had 
resulted in loss of appetite, and if under the influence of abstinence we indeed 
did see the sugar diminish, we observed at the same time a circumstance of 
great gravity, namely, enfeeblement of the forces. On this account we yielded 
to the desire of the patient, and allowed her a small quantity of bread with each 
meal. What we did you will often have to do, but take care always to test the 
results of your dietetic prescriptions by daily analyzing the urine, and in this 
analysis the saccharimetric process of Duhomme will render you great service 
in enabling you expeditiously to examine each day the effects of alimentation. 
The hygiene of the diabetic does not exist exclusively in attention to diet, it is 
necessary also by physical exercises, varied and multiple, to energize the com- 
bustion of hydro-carbonaceous matters. Here, moreover, it is Bouchardat 4 

Parmesan cheese; chiccory, lettuce, and other herbaceous vegetables; asparagus, spinach, 
mushrooms, etc. If tea and coffee (which should never be sweetened) have no influence 
favoring the glycosuria they may be indulged in. Alcoholic liquors should be used with 
great moderation. Of wines (a quart a day for a man, a pint for a woman), choose the old 
red wines or the old white wines (Madeira, Chablis, Pouilly, Sauterne, Rhine, etc.) — Trans.] 

3 The alimentary regime of Seegen is very similar to that of Bouchardat, only it is 
more strict. He allows without restrictions all meats, all kinds of fish, mollusks, and crus- 
tacean, gelatine, eggs, cream, butter, cheese, pork, spinach, lettuce, chicory, asparagus, 
pumpkins, cresses, artichokes, mushrooms, nuts, and among the beverages, soda water, tea, 
coffee, Bordeaux and Rhine wine, and all the other wines such as are mostly devoid of 
sugar and alcohol. He also permits in small quantity, cauliflowers, carrots, parsnips, cab- 
bage, green beans, raspberries, gooseberries, strawberries, oranges and sweet almonds; in 
very trifling quantity, milk, cognac, bitter ale, milk of almonds, lemonade without sugar. 
He absolutely forbids all farinaceous substances (except a very small quantity of bread, which 
the physician may permit in certain instances), sugar, potatoes, rice, tapioca, sago, arrow 
root, semoule, legumes, green peas, beets, sweet fruits, especially grapes, cherries, peaches, 
prunes, apricots, and all dried fruits, sweet and frothy wines, sherbet, cocoa, chocolate, 
etc. (a) 

4 These are Bouchardat's views respecting exercise: 

Considering the importance of exercise, it is well to recommend such exercises as will 
tempt the patient to indulge in them every day. 

Among these we recommend to persons fond of the chase, fencing, military exercises, 
rowing, skating, lawn tennis, ball playing, billiards, croquet; in a word, all the active sports, 



(a) Seegen on Saccharine Diabetes. Leipsig, 1870. 



ON THE TREATMENT OF DIABETES. 303 

who has furnished the best indications to follow in the forced exercise of dia- 
betic patients, and you will find described with a great deal of humor the main 
features of these forced exercises iu the spirited work of Jules Cyr. All that 
can augment the forces of the economy ought to be employed in these cases, 
and it would be well to vary these exercises according to the needs of the pa- 
tients. Gymnastics, fencing, forced marches, work in the garden, manual exer- 
cise, carpentry, all have their place and their use. You may even add to these 
means, inhalations of oxygen, baths of compressed air, inhalations of compressed 
air, in a word, all measures which may increase the organic combustions in 
rendering more active the respiratory functions. In fine, Bouchardat has also 
insisted on the necessity of special attention to the functions of the skin. You 
know, in fact, that in grave cases of diabetes the skin becomes dry and rugose, 
hence warm baths followed by massage are useful in such cases, and may be 
taken two or three times a week. 

With this hygienic treatment you can in mild cases cause the glycosuria 
absolutely to disappear. In diabetes of medium intensity you will consider- 
ably lower the amount of sugar, but you will have to conjoin certain medicines, 
and it is these medicaments which 1 am now going to consider. I propose to 
pass rapidly over the pharmaceutical agents whose medicinal action in diabetes 
is not satisfactorily demonstrated, to dwell more particularly on three of them 
which possess marked curative virtues. I refer to the alkalies, arsenic, and 
bromide of potassium. 

Certain antiseptic remedies have been much vaunted these late years, such 
as salicylic acid and carbolic acid." Ebstein and Muller, Ryba and Plumert, 
Fischer and Peters have recommended this method of treatment. According 
to Fiirbringer, these anti-fermentescible substances are much superior to the 

without omitting the ordinary manual labors, such as sawing, splitting wood, employment in 
the garden, digging, chopping, the care of animals, etc. For women we prescribe all the 
active labors of house-keeping, especially those which require walking about, For both men 
and women, long daily walks are beneficial, and if they exert themselves occasionally to run 
it is no harm. 

Exercise which requires constant standing without walking is rather to be avoided as 
favoring swellings of the lower extremities, etc., and of all exercises those should be chosen 
which agree the best with the patient, and are sufficiently active to cause frequent perspira- 
tion, frequent changes of the undergarments being desirable, and all necessary precautions 
to avoid catching cold, (a) 

5 Wilhelm Ebstein and Julius Muller have employed carbolic acid in diabetes and ob- 
tained favorable results, especially in the diabetes of fat people; the dose which they gave 
was five grains daily in peppermint water (in divided doses). Salicylic acid had no effect 
whatever. In the experience of Purgesk phenic acid was without result, while salicylic acid, 
in doses from five to ten grammes a day, proved curative. Peters has also employed salicy- 
late of soda in fourteen cases, in doses of eight to ten grammes a day. He affirms that by 
this means light cases can be cured, and grave cases considerably ameliorated. In Kamen's 
trials the result was nil as far as the glycosuria was concerned; in some cases serious gastric 
troubles resulted from the salicylic medication. 



(a) Bouchardat, on Saccharine Diabetes. Paris, 1875. 



304 ON THE TREATMENT OF DIABETES. 

other pharmaceutical agents. 1 The trials which I have made with these med- 
icines on divers of my patients, both in hospital and private practice, have not 
given me such good results. I have not observed notable diminutions in the 
sugar, and I have seen, like Kamen, gastric troubles, and I believe there is risk 
in administering large doses of these phenols to some diabetic patients by reason 
of the bad state of their kidneys. To these medicaments we must add perman- 
ganate of potash, proposed some time ago by Sampson, of London, and which 
Masoin, of Louvain, has recently brought into vogue. 2 This permanganate of 
potash may have a good effect on diabetes of hepatic origin. Cantani has as- 
serted the favorable action of lactic acid in the treatment of diabetes. Pie 
thinks that this acid favors the digestion of animal food and the organic com- 
bustions; 3 it is even, according to him, the unique medicine to give to the 
diabetic. As I have never advised the exclusive diet of the Italian physician, I 
have not used his pharmaceutical treatment. I cannot, then, give you any infor- 
mation on the employment of lactic acid. Ogles pretends that this medicament 
diminishes the quantity of sugar, but at the same time lessens the weight of the 
patient. 

1 Fiirbringer has studied the action of different medicinal substances in diabetes. In 
the first rank he places salicylate of soda and phenic acid, which diminish notably the quan- 
tity of sugar eliminated by the urine. 

Quinine, arsenious acid, pilocarpine and benzoate of soda have no influence either on 
the quantity of sugar or on the production of urea. 

2 Permanganate of potash was introduced into the therapeutics of diabetes by Sampson, 
of London. Masoin, of Louvain, made trials of it in 1875, an d claimed good results. He 
explains the beneficial effects of permanganate of potash by the action which manganese 
exercises on the liver, which organ he believes to be the point of departure of saccharine 
diabetes, (a) 

3 Dr. Forster, in his "Contributions to the Therapeutics of Diabetes Mellitus," reports 
eleven cases of diabetes treated by the following medicaments: 

Oxygenated water, ergot of rye, salts of potassa, opium, bromide of potassium, and 
lactic acid. 

The oxygenated water gave no result; ergot of rye, in the form of extract, diminished 
the quantity of urine without diminishing notably the quantity of sugar; the salts of potassa 
carbonate and citrate had no effect; opium produced a diminution both in the quantity of 
urine and sugar; bromide of potassium caused also a diminution, but this was slight; lactic 
acid, in the dose of three drachms a day, diminished the quantity of sugar, and seemed to 
give good results along with a diet of skim milk. This is the way that Cantani administers 
lactic acid: 

After each meal, i. e., three times a day, the patient should take in six successive doses, 
half an hour apart, the following solution : 

^ Acid lactic, 2 grammes ( 3 ss). 
Pure water, 120 grammes ( § iv). 
M. Sig. — Take l /e part for a dose as above directed. 

He directs also to be taken, alternately with the alkaline waters of Vichy or Vals, a 
lactic acid lemonade, thus prepared: 



(a) Sampson, Lancet, 1853. Masoin, on the Treatment of Saccharine Diabetes by Permanganate of 
Potash. Belgium, 1882. 



ON THE TREATMENT OF DIABETES. 305 

Struck with the action of certain narcotics, such as opium, belladonna, 
valerian, on the quantity of urine voided each day, it has occurred to physicians 
to reduce the polyuria of the diabetic by the use of opium, 4 and it is on this 
principle that Willis, Rollo, and Tomasini have advised this medication. Dia- 
betic patients, in fact, bear opiates well even in large doses, and you may note 
in some of them a diminution of urine and in the quantity of sugar, but this 
result is obtained at the sacrifice of the digestive functions and of the appetite. 
This is an evil which attends the use of a great many pharmaceutical prepara- 
tions, and is to be avoided. To lessen the sugar in the urine by diminishing 
the appetite and troubling the digestive functions is to render a very poor serv- 
ice to the diabetic. 

Valerian is more applicable to diabetes insipidus or polyuria than to saccha- 
rine diabetes. Trousseau has shown that under the influence of this medica- 
ment there is a diminution in the quantity of urine, on condition always of 
giving large doses, and he was in the habit of administering as much as an 
ounce a day of the extract. Ergot of rye acts also against polyuria rather 
than against glycosuria, and Huchard has recently shown the good effects which 
may be obtained from the spurred rye in diabetes insipidus. 

Iodine and the iodides have also been employed in the treatment of 
glycosuria. Ricord, Berenger-Feraud, Rayer, and Seegen principally have 
exhibited the tincture of iodine in the dose of from twenty to thirty drops a 
day, and have seen the sugar disappear from the urine, but it is an irritant 

^ Pure lactic acid, 5 to 20 grammes. 
Peppermint water, 20 to 30 grammes. 
Spring water, 1 litre. 
M. Sig. To be freely used as a drink. 

Dr. Ogles has employed lactic acid in diabetes and noted a considerable diminution in 
the quantity of urine, but the patient lost his strength, (a) 

4 Opium has been given in the form of aqueous extract in the dose of 50 centigrammes, 
as in the practice of Christian, Ormerod, Schutenberger, and Pavy. Monez, Tomasini, and 
Kratchmer increase the dose to 3 grammes a day. There is not agreement as to the real 
action of opium in diabetes. Bouchardat thinks that it acts by promoting diaphoresis; 
Brouardel, by modifying the nervous system; Pecholier and Lecorche regard it as a tissue- 
sparing medicament, lowering the proportion of urea excreted. 

[Codeia is much more generally used at the present day, especially in this country and in 
England. Dr. Pavy (Guy's hospital, Rep., 1870) was the first to recommend codeia as being 
signally efficacious in controlling diabetes without exerting the narcotic effect of opium or 
morphia. The proper commencing dose is gr. ss thrice daily, which may be gradually 
increased to gr. ij-iij. Dr. A. A Smith, at a seance of the Academy of Medicine, New York, 
1882, reported in favor of treatment by codeia, having found it curative, in conjunction with 
perchloride of iron, in several severe cases. The dose of codeia was the same as that above 
mentioned. The dose of the tincture of iron was 20 drops three times a day. A laxative 
aloetic pill was given at bedtime. 

In my own practice I have seen glycosuria often disappear under codeia, coupled with 
an animalized dietary regime. — Trans] 



(a) Ogles, Two Cases of Saccharine Diabetes Treated with Lactic Acid. Brit. Med. Journal, March, 

1879. 

§20 



306 ON THE TREATMENT OF DIABETES. 

medicament and fatiguing to the stomach. I pass rapidly over the chalybeates, 
phosphorus, cantharides, pilocarpine, 1 the juice of cana-agria? to arrive, at 
last, to the consideration of the alkalies, arsenic, and bromide of potassium. 

The alkalies are the most precious pharmaceutical agents in the treatment 
of diabetes, although we have no very clear explanation of their therapeutic 
action. Mihale having pretended that glycaemia depends on want of alkalinity 
of the blood was one of the first to recognize the utility of alkaline medi- 
cation, but, as Becquerel and Lapezzuoli have shown, this is a mistake, for 
the blood of diabetic patients presents no modification in its alkaline reaction. 

It is probable that in diabetes the alkalies have a complex action; they 
regulate the digestive functions, and energize the functions of nutrition (as 
shown by the researches of Hyades and Martin Damourette), in fine, it is pos- 
sible that they have, as Coignard thinks, a direct action on the glycogenic 
functions of the liver. 3 

Many alkaline preparations have been prescribed; some, as Rollo, Willis, 
Fothergill, and Wat, have counseled lime-water; others, as Dur, Neumann, Bar- 
low, Adamkiewicz, prefer the ammoniacal salts; Bouchardat and Pavy have 
especially advised the carbonate of ammonia. 4 

Potassa has also been exhibited, and Bouchardat, who cannot be too much 
cited when diabetes is under consideration, has proposed to substitute for the 
common salt in the ordinary dietary of the diabetic the potassic tartrate of 
soda, known as Rochelle salt. This preparation he considers superior to citrates 
of soda and potassa, which he was formerly in the habit of prescribing. He 
even advises the use of the Seidlitz salt in the preparation of diabetic bread. 

1 Hoffer has made trials of pilocarpine in diabetes in the form of subcutaneous injec- 
tions. He noted diminution in the quantity of urine and of sugar. 

2 The juice of cana-agria is a popular remedy for diabetes in South America. Botanical 
data concerning this plant are wanting. Gubler, in doses of three ounces a day of this juice, 
observed diminution of sugar, (a) 

3 Coignard has studied the action of alkalies on the glycogenic function of plants and 
animals. He shows that when you water vegetables, such as beets and gooseberry bushes, 
with alkaline solutions you notably diminish the quantity of sugar which they contain. 

He pretends to have arrived at complete suppression of the glycogenic functions by 
means of these waterings. He reasons that the same phenomena may take place in man 
when alkalies are taken internally, {b) 

4 Bouchardat claims good results from carbonate of ammonia, which he administers 
in large doses (as much as can be borne without vomiting) in rum and water. Dr. J. M. 
DaCosta's formula (Naphey's Medical Therapeutics, Geo. S. Davis, publisher), is as fol- 
lows : 

1$ Carbonate of Ammonia 3 ij — 3 iv. 
Aquae Cinnamoni § vi. 

M. Sig. A tablespoonful three or four times a day. 






(a) Journ. de Ther., 1877. 

(<5) Coignard: "Alkalies may annihilate the glycogenic function in plants and diminish its activity in 
man." Journ. de Ther. 1880. 



ON THE TREATMENT OF DIABETES. 307 

But the alkaline salt the most employed in the treatment of diabetes is the 
bicarbonate of soda, and here we must give the preference to the natural alka- 
line waters over the artificial waters, which fatigue the stomach, and cannot be 
borne for any great length of time. You will then order your diabetic patients 
to drink with their meals waters with but a moderate degree of alkalinity, say 
two or three grammes per litre, and there is nothing better than the Vals or 
Vichy waters. 

Arsenic has these late years been much extolled in the treatment of gly- 
cosuria. 1 It has been supposed that arsenic, in modifying the constitution of 
the liver, modifies also the glycogenic functions, and the recent experiments of 
my colleague, Quinquaud, have shown that this medicament always diminishes 
in animals glycaemia, glycosuria, and glycogenesis. This is a fact of great im- 
portance, and shows us the advantages which may be derived from arsenical 
medication in diabetes. Fowler's solution is the best form to choose; of this 
you need not fear to give large doses, even twelve to fifteen and twenty drops, 
according to the tolerance of the digestive tube. 

Arsenic is not the only metal or metalloid used in diabetes, iodine has been 
prescribed, and even copper and mercury, the first by Franck and Berndt, the 
second by Brera and Scott. Burq has even thought that his process of metallo- 
therapy and metalloscopy has a field of usefulness in these cases. 

The attention of the medical world has of late been called to the curative 
action of bromide of potassium 2 in diabetes by a very interesting communi- 
cation by Dr. Felizet to the Academie de Medecine. Felizet has shown that in 
certain cases in following the dietetic regime of Bouchardat and the alkaline 
medication by bromide of potassium, one may free the urine entirely of the 
sugar which thus far has persisted in making its presence manifest. 

This is a kind of treatment which was counseled by Beghie in 1866, 

1 There has been much discussion as to the value of arsenic in diabetes, good authori- 
ties claiming that it is beneficial— and among these Jaccoud, Foville, Lecorche; others, as 
Furbringer, that it is wholly without effect. 

Quinquaud performed a curious experiment. He gave to animals subcutaneous injec- 
tions of twelve to fifteen drops of Fowler's solution, then he pricked the floor of the fourth 
ventricle, and a subsequent examination of the urine, the liver and the blood found a notable 
diminution in the quantity of sugar; when the dose is sufficiently large to produce poisoning 
there is complete disappearance. 

The same phenomenon takes place in patients to whom twelve to twenty drops of 
Fowler's solution are daily given medicinally, (a) 

2 The treatment by bromide of potassium was first employed by Beghie who published 
four cases where the employment of bromide effected cure of the diabetes. 

Forster, in 1872, repeated the experimentation and obtained equally good results. 
Bouchardat has also made use of bromide; finally, in 1878, Furbringer experimented with 
it and obtained bad results. 

In his communication to the Acad. Med , Felizet has called attention to the clinical 
facts and the facts of experimentation. 

As for the clinical facts he has shown that in fifteen cases of diabetes, bromide alone or 
associated with the dietetic treatment of Bouchardat, and the employment of alkalies caused 



(a) Lecorche\ Treatise on Diabetes, 1877. 



308 ON THE TREATMENT OF DIABETES. 

but which being tried anew by other physicians, had not given very favorable 
results. In the trials which I made in my service, and in the report which I 
presented to the Academy of Medicine on this subject, while recognizing the 
fact that bromide of potassium in the dose of one to two grammes a day may 
cause glycosuria to disappear, just as Felizet had announced, I showed that the 
use of this medicine is not without inconveniences. It depresses considerably 
the forces, and this depression is sometimes so great that the patient is not 
able to leave his bed. I think, then, that it is necessary to be very prudent in 
the administration of medicaments of this character, and reserve them for cases 
of diabetes of nervous origin, and for patients sufficiently vigorous to sup- 
port such treatment. 

The thermal treatment of diabetes is of preponderating importance, and 
the results which may be derived from it are based on the physiological 
effects of alkalies and arsenical salts in glycosuria. It is, then, to the alka- 
line and arsenical spas that you should send your patients, and you may utilize 
the alkaline waters of Vichy and of Carlsbad, or those of Royat and Bourboule 
if you desire especially for your patients the constitutional effects of arsenic. 

I shall have finished this long enumeration of the means of treatment of 
diabetes when I shall have said a few words about the local treatment of diabetes 
by electricity, hydrotherapy, setons, and cauteries. 

It was Semmola who, in 1861, first recommended the employment of con- 
stant currents upon the pneumogastric in the treatment of diabetes. Leidel 
and Prof. Leon Le Fort have obtained good results from galvanism. 

Fleury has counseled hydrotherapy. I believe that it is necessary to be 
very careful in the use of this hygienic remedy, and not to employ it except 
when your diabetic patients are robust, and capable of vigorous reaction. 

The same prudence should be exercised in the use of setons and 
cauteries. Butura and more recently Boutigny have noted cases of diabetes 
where complete disappearance of sugar from the urine followed the application 
of cauteries and setons in the region of the neck. But you should remember 
the danger of wounds (which do not readily heal) in the case of diabetic 
patients, and be extremely cautious about attempting treatment of this kind. 

Such are the therapeutic rules applicable to the treatment of diabetes. 
Here the dietetic regimen is far the most important, all other modes of treat- 
ment being accessory means whose real value is often more or less debat- 
able. But whatever this value may be, the combination of these means none 
the less constitutes an efficacious system of therapeutics, and without daring 



the disappearance of sugar in diabetic patients. Since then he has observed fourteen new 
cases where he obtained the same effects. Herard and Dreyfusbrisac noted the same 
results. Dujardin-Beaumetz made trials of bromide of potash in three grave cases of dia- 
betes without result except a considerable lowering of the vital forces of the patient. He 
recommends to employ this medicine with extreme caution, (a) 



{a) Beghie, Edinb. Med. Journ., Dec, 1866.— Forster, British and Foreign Med. Clinic Review, 
1872, p. 48.— Furbringer, Deutsche Arch. Klin. Med., p. 469, 1878.— Dujardin-Beaumetz, Sur le traitement du 
diabete par le bromure de potassium, Acad, de Med, seance du 28 Aug., 1883. 



ON THE TREATMENT OF DIABETES. 309 

to affirm, as some have done, that diabetes is to-day a disease easily and 
certainly curable, I believe that in a very great number of cases we can have 
a useful and real influence on the disease, and this is why I have devoted 
so much time to the consideration of these details. 



ON THE TREATMENT OF SYPHILIS. 

Summary. — Origin of Syphilis — Necessity of the Mercurial Treatment of Syphilis — Mercury 
— History — Absorption of Mercury — Its Elimination — Elimination by Milk — Mercurial 
Salivation — Anti-Syphilitic Action of Mercury — Mode of Introduction of Mercury 
— Dermic Method — Mercurial Frictions — Mercurial Baths — Hypodermic Methods — 
Injections of Ammoniaco-Mercurial Peptones — Respiratory Method — Dermo-Pulmo- 
nary Method — Mercurial Inhalations — Method per Os — Mercurial Preparations — Adju- 
vant Medications — Vegetal Treatment — Guaiacum — Pilocarpine — Iodide of Potassium — 
General Treatment — Method of Successive Treatments — Concerning the Cure of 
Syphilis — The Marriage of Syphilitic Persons — When Ought the Anti- Syphilitic Treat- 
ment to be Commenced ? — Necessity of Treatment — Are all the Manifestations of 
Syphilis Tributary to the Specific Treatment ? — Treatment of the Indurated Chancre — 
Iodoform — Sulphide of Carbon — Treatment of the Stages — Mixed Treatment — Treat- 
ment of Mucous Patches — Treatment of Tertiary Syphilis — Treatment of Venereal 
Affections — Soft Chancre — Blenorrhagia — its Treatment — Cubebs and Copaiba — 
Urethral Injections — Treatment of Gleet — Abortive Treatment — Blennorrhagic Vaginitis 
— Vaginal Suppositories — Gurgun Balsam — Vaginal Injections. 

Gentlemen: In the exposition which I desire to make of the treatment 
of syphilis, I shall endeavor to be as brief and as practical as possible. I shall, 
then, put aside the great questions which a consideration of treatment raises, 
and especially those pertaining to public hygiene and prophylaxis which are so 
earnestly discussed to-day, and shall concern myself exclusively with the means 
which will enable you to cure as speedily as possible the various manifestations 
of venereal disease. 

Syphilis is unfortunately a malady whose frequency increases daily, and 
whose symptoms you will in your practice have to combat a great many times. 

I shall not, then, discuss before you the origin of venereal disease. 1 It is 
probable that, like the greater number of diseases which afflict humanity 
syphilis was known in the first periods of the human race, and if we may credit 

1 Historians relate that at the end of the fifteenth century (1495) occurred the first out- 
break of syphilis in France, at the time of the French expedition against the Neapolitans; 
the French called it Italian plague, the Italians gave it the name of French plague. Fra- 
castor has given us the most complete description of this epidemic, but an attentive study of 
the facts shows that syphilis existed a long time before but was only known by certain 
isolated manifestations. 

In China syphilis has existed from all antiquity, and in a book which goes back to 
B. C. 2637, and is attributed to Hoang-ti, you will find a description of all the syphilitic 
accidents; the account of chancre is especially good 

In India also a very exact account of syphilis and its many symptoms is contained in 
the Sucrutas-Ayurvedas, which may be considered as the Hippocratic treatise of Indian 
medicine. 

According to an Indian myth Cira, having given himself up to sensual indulgences, 
was punished by gangrene of the genital organs; and this disease spread over the whole 
world by contagion, only yielding, if ever, to the prayers of the penitents. 

The Jews, Greeks, and Romans also had a knowledge of syphilis. The disease of Job 
bears striking resemblance to syphilitic dermatosis. The Greeks had a religious myth similar 

310 



ON THE TREATMENT OF SYPHILIS. 311 

Parrot, the prehistoric man was not exempt from it. Nor shall I discuss the 
necessity of mercury in the treatment of syphilis; this question seems decided 
at the present day, and it would be to gainsay the clearest evidence not to ad 
mit the efficacy of mercurials in this disease. I am well aware that abuses have 
been made of this remedy; that not all cases of syphilis are curable by quick- 
silver; that the treatment is not suitable to all periods of the malady; but what 
I cannot understand is the obstinacy of a small, though influential, number of 
physicians, who refuse to acknowledge, as demonstrated, the marvellous action 
of mercury in a great many cases of syphilis. 2 

It suffices to have been an attentive observer, during one's practice, of a 
few cases of syphilis with cerebral complications of great gravity, and to have 
seen them disappear as by enchantment under the influence of an energetic 
mercurial course, to compel one to admit, without reservation, the therapeutic 
power of mercury in syphilis. I am going, then, to set forth at some length 
the fundamental principles of this hydrargyrate medication. 

Considered by the writers of antiquity as one of the most energetic 
poisons, 3 mercury was used externally by the Arabs; Rhazes recommended 

to that of the Indians. Some of the Latin writers describe phenomena which clearly apper- 
tain to syphilitic affections. 

Modern anthropological researches justify these views. Parrot has shown on the 
bones of prehistoric man morbid alterations clearly of syphilitic origin, at least according to 
Broca, who is good authority. 

In the prehistoric burial places of the new world St. John has also found exostoses of 
the same nature . 

2 Although in the sixteenth century there was vehement opposition to the mercurial 
treatment of syphilis, and Fernel in particular protested against its employ in this disease, 
the war against the hydragyrate treatment has been waged with the greatest violence in 
this present century. Broussais began it in France by decrying the specificity of syphilis 
and recommending the antiphlogistic medication. His followers, Dubled, Bobillier, 
Richoud des Brus, have gone so far as to affirm that the accidents observed in syphilis 
are due to mercury. 

Murphy, in England, took this view in 1839, an( i Joseph Hermann, in Germany, 
made a veritable crusade against this medication. 

Lorinser has carried the opposition even farther, and basing his views on the re- 
searches of Kletzinsky, and Melsens, who affirm that iodide of potassium eliminates 
mercury, he maintains that this last medicament benefits only in this way in syphilis. 

At the same period in France Anzias-Turenne repudiated mercury quite as absolutely, 
and proposed syphilization as a means of treatment, and he was followed in this line by 
two foreign practitioners, Sperino, of Turinne, and Boeck, of Christiana. 

Coincidently with these labors there was made a study of the natural evolution of 
the disease which commenced by the observation of William Fergusson, who during the war 
between France and Portugal in 1813 noticed that the Portuguese soldiers treated without 
mercury got well quite as rapidly as the English soldiers treated with it. John Thompson, 
in England, Boerensprung, in Germany, and Diday, in France, showed that a considerable 
proportion of syphilitic cases get well without mercurial treatment. To these names we 
should add that of Despres, who has distinguished himself as one of the most bitter 
adversaries of mercury. 

3 The ancients made little use of mercury as a medicine for they regarded it as a 
poison. Galen, Dioscorides, Aretseus, attributed to it tonic properties. The Arabs, while 



312 ON THE TREATMENT OF SYPHILIS. 

mercurial applications as part of the treatment of tinea, of scabies, of the 
mange, and of all wounds of bad nature, and as it is the property of syphilis 
to produce cutaneous ulcers of foul aspect, it is easy to understand how, 
from the appearance of the epidemic of syphilis at the end of the fifteenth 
century, this medicament came to be used in the treatment of these sores. 
It is then a matter of history that Marcellus Cumanus in 1495, Casper Torella 
in 1497, Conrad Gilini still later employed mercurial ointment in the treatment 
of the grave cutaneous affections which were observed in France and Italy as a 
sequence of the siege of Naples. 

The introduction of mercury into practice as an internal remedy was of 
later date, and it was not till 1536 that Matthiolus dared prescribe it internally 
for syphilis, and since this epoch down to the present time, the medical profes- 
sion has not ceased to administer this medicament, and to note its good effects. 
Notwithstanding the multiplicity of works on this subject, we are ignorant of 
the modus operandi of this remedy, and while no medicine is in so general use in 

admitting its deleterious properties, recommend mercurial preparations for outward use in 
itch, mange, and to kill lice. Rhazes and Serapion give for these purposes very precise 
formulas, which were brought again into vogue in the thirteenth and fourteenth centuries 
by Theodoric (1280), and Arnaud de Villeneuve (1300). It was as a result of these topical 
methods of using mercury that mercurial ointments came first to be employed in the 
treatment of syphilis, and they were utilized at the time of the first outbreak of syphilis 
in Europe, in the fifteenth century. 

In 1495 Marcellus Cumanus, physician to the Venetian army, recommended a mer- 
curial pomade consisting of quicksilver in combination with oil of sweet almonds and 
lead lotion. 

Gaspard Torella in 1497, and Conrad Gilini in 1498, also speak of mercurial ointments 
as external applications in syphilitic ulcers. Metallic mercury was in use as well as 
cinnabar and corrosive sublimate in ointments, plasters and fumigations. 

Jean de Vigo in 15 18 was the first to administer red precipitate, not for pox, but for 
the plague. Several years later Matthiolus prescribed it in syphilis. The year following 
(viz., 1537), Pierre de Bayrs, physician to Charles II., gave a recipe for some pills which 
Barberousse, King of Algiers, Captain Gen. of the Turks, during the reign of Soloman II., 
had sent to his ally, Francis I., who was suffering from the venereal disease. These pills 
contained metallic mercury associated with rhubarb, aloes, amber, mastic and myrrh. At 
this epoch not only was the external and internal use of mercury known, but also all the 
dangers attending this medication, which was very popular and largely in the hands of 
quacks, and nothing is more curious than the narrative which Ulrich von Hutton has 
given, who, having had the pox, was subjected eleven times during nine years to mercurial 
treatment, from which he experienced cruel sufferings. 

Astruc has also given us a touching account of the unhappy victims of syphilis under 
mercurial treatment: "As their mouth was one fetid ulcer, and their stomach was enfeebled, 
they had no appetite; many were attacked with vertigo, some with madness; they were seized 
with a trembling of the hands, of the feet, and of the whole body, and they were subject 
to a stuttering often incurable; I have seen a great many die during the treatment." It was 
at this epoch that the reaction against mercury took place, and sudorific woods, guaiacum 
in particular, were introduced into the treatment of pox. Physicians were then divided into 
mercurialists and anti-mercurialists. (a) 



(a) Gaspard Torella, Tractatus eum consiliis y Romse, 1497.— Rhases, Ad Almansor^ 850, lib. IX.— 
Serapion, Libro de sim.plici medicina. — Mesue, In antidotario. — Ulrich de Hutten, De guaiaci medicina et 
morbo gallico, Magientice, 1519. — Hollopeau, Du mercure (these d'agregation, 1878). 



ON THE TREATMENT OF SYPHILIS. 313 

syphilis, there is none whose physiological action is more obscure. I am, never- 
theless, going to give you some information which we possess relative to the 
ways of absorption and elimination of mercury, and I will do this, taking as my 
principal guide the remarkable work which my colleague in this very hospital, 
Dr. Hallopeau, has devoted to this medicament. 1 Mercury may penetrate the 
economy, either by the digestive tube, by the respiratory passages, or by the 
skin, and therapeutics utilizes all of these ways. 

There has been much discussion about the penetration of mercury by the 
skin. It is known, in fact, that quick-silver, when finely divided, as it is in 
mercurial ointment, may enter the economy through the skin, when not devoid 
of its epitfielium, and this is one of the methods by which salivation may be 
most rapidly produced. How does this penetration take place? Some, as 
Overbeck, Eberhards, Oesterlen, have pretended that mercury in the metallic 
state penetrates the subcuticular vascular network. Others, as Rindrleisch, 
have maintained that this penetration of mercury in the metallic state is impos- 
sible, and that it is only after having been transformed into a soluble chloride 
by the sudoral secretion, that quicksilver enters the economy. The recent 
experiments of Fleischer give much support to these last views. 2 

It is then in the state of chloride, and especially of bichloride, as Mialhe 3 

1 Hallopeau. De Mercure These d'agregation. Paris, 1880. 

2 The claim has been made that mercury may directly penetrate the vessels in metallic 
state, when frictions with mercurial ointment are made. Oesterlen pretends to have found 
globules of mercury in the blood of cats over whose skin he practiced mercurial frictions. 
Eberhard and Overleck affirm that mercury filters through the skin, and that they have found 
it even in the sub-pleural tissue, while Blomberg claims to have found metallic mercury in 
all the tissues. 

Fleischer has recently taken up this study, and from very conclusive experiments he 
has proved that if mercury penetrates the more superficial layers of the epidermis, it never 
reaches the rete mucosum. 

A great number of authorities agree in affirming that in the case of frictions with mer- 
curial ointments, absorption takes place in two ways: by the lungs, and by the transformation 
of mercurous or mercuric oxides into chlorides, (a) 

3 Mialhe has pretended that mercury does not penetrate the system except in the state 
of bichloride, or in the form of an alkaline hydrargyrate-chloride. The protoxides undergo 
transformation, he thinks, into protochlorides, and then into bichlorides. 

Voit admits the same thing — to wit, that the suboxides undergo transformation into 
calomel, and the oxides into bichloride; these last unite with the chloride of sodium and 
albumen of the blood. 

The recent investigation of Bucheim, and of Ottingen, and those of Otto Graham make 
it appear probable (contrary to the views of Mialhe) that the protochloride combines with 
albumen to form an assimilable albuminate of protoxide of mercury. 

Bellini has studied the modifications which the chlorides, the bromides, and the iodides 
undergo. Calomel, according to him, dissolves in the stomach and in the intestines under 



(«) Rindfleisch (Ed.), Zur Frage von der resorption des regulinischen qztecksilbers {Arch, der Dermatol., 
t. II, p. 309, 1879).— Overbeck (Rob.), Merctir und syphilis. Fhysiologische-chemische und patholngiscke 
Untersuchungen das quecksilber and iiber die quicksilberkrankheit, Berlin, 1861.— Blomberg, Nagra ord 
om quicksil/vrets absorpcion af organismen, Helsingfors, 1067. — Hallopeau, Du mercure (these d'agre- 
gation, 1878. 



314 ON THE TREATMENT OF SYPHILIS. 

affirms, that all mercurial preparations enter the blood, combined, be it under- 
stood, with the albumen of the blood, thus constituting a double albuminate or 
peptonate of hydrargyrum and of sodium. 

When once it has penetrated the blood, mercury, after having sojourned a 
variable time in the economy, is eliminated by drvers emunctories, in partic- 
ular by the kidneys, by the faeces, by the milk, by the sweat, and by the saliva. 
The duration of this elimination depends on the duration of the mercurial 
treatment, and when this has been very prolonged, one may find mercury in the 
urine for several weeks after the treatment has been discontinued. Mercury 
seems, in fact, to fix itself in different viscera, and in particular in the liver. 4 It 
has been maintained that it is this fixation of mercury in the bones which pro- 
vokes those osteocopic pains so frequent in the advanced periods of syphilis. 
This interpretation is absolutely erroneous, for there are syphilitic patients who, 
never having followed any mercurial treatment, have osteocopic pains of the 
most violent kind, and these pains seem to be mitigated under the influence of 
mercurial preparations. 

Among the channels for elimination of mercury, there are two which inter- 
est the therapeutist— the mammary and the salivary glands. The fact of elim- 
ination by the saliva explains the cause of the salivation which so frequently 
attends the mercurial treatment. It is, in fact, maintained that it is the presence 
of chlorides of mercury in the saliva which is the point of departure of the 

the influence of chlorides and lactic acid, being transformed into a double chloride of mercury 
and sodium and into lactate of mercury. The iodides and the bromides undergo a similar 
change, being transformed into double salts under the influence of the alkaline chlorides and 
lactic acid. A part of these salts enters the circulation, another part is transformed into 
sulphide of mercury in the large intestines, and eliminated in the faeces, (a) 

4 The elimination of mercury is effected by the kidneys, intestines, mammary glands, 
perspiratory and salivary glands. The utility of this last kind of elimination has been much 
disputed of late years, yet Bernaski has determined the presence of mercury in the saliva 
taken directly from Steno's duct. 

Personne, Blinz, Lewald, and Klink have found mercury in the milk of nurses sub- 
mitted to mercurial treatment. 

Riederer has examined experimentally the quantity of mercury eliminated by the 
different emunctories. In an animal which had taken, in twenty- nine days, nearly two 
grammes of mercury, during this time four per cent, was found in the faeces, nine per 
cent, in the urine, and during the succeeding eighty-one days there was still found in 
grammes and fractions of a gramme, .0568 in the faeces, .0040 in the urine, and .0026 in 
the liver. 

Mayencon and Bergeret have studied the rapidity of elimination of the mercurial 
preparations. Experiments show that the greater part of the medicament is immediately 
eliminated in the urine, and that another part, after having become fixed in the tissues, is 
eliminated very slowly and insensibly, insomuch that several days after the cessation of the 
mercurial treatment the presence of mercury is detected in the urine, (b) 



(a) Rindfleisch, Arch, de Dermatol., t. ii, p. 309. Overbeck, Mercure und Syphilis, Berlin, 1861. 
Hallopeau, Th. d'agregation, 1878. Voit, Physiologie, Chemische Untersuchungen, 1 Heft, Augsbourg, 1858. 
Blomberg, Nagra ord om quicksellfvrets absorpcion, af organismen, 1867. 

(b) Bergeret and Mayencon, " Clinical Means for Recognizing Mercury in the Excretions, and princi- 
pally in the Urine;" Lyon Medical, t. iv., 1873, P- !70- 



ON THE TREATMENT OF SYPHILIS. 315 

irritation of the mucous membrane of the gums. At the same time this point 
of pharmaco-dynamic action demands to be studied anew, for the salivation 
seems to depend especially on the mode of administration of the mercury. 
Very easily provoked by cutaneous inunctions, it is exceptionally produced by 
hypodermic injections. 1 

Can we find in the physiological and toxicological action of mercury the 
explanation of its anti-syphilitic action? Unhappily, no; and the study of 
mercurialization, whether slow and chronic or sudden and acute, observed so 
often in men who work in industries where mercury is in use, does not furnish 
us any data for the solution of this important therapeutic question. 

It has been said that mercury acts on the blood-globules and the plasma; 
this may be true in the normal state, and when it acts as a poison. But this is 
the very opposite of what takes place in syphilitic patients, where one con- 
stantly sees under the influence of a well-regulated treatment, the number of 
red globules augment, as well as their richness in haemoglobin. The experi- 
ments of Wilbouchewitz of Moscow, of Keyes, of Robin, of Schlesinger, are 
absolutely confirmative in this respect. Mercury cures syphilitic anaemia, but 
it is powerless to benefit other anaemias. 3 It is necessary then to admit that 
mercury possesses a specific property in the treatment of syphilis, and we 
are obliged to content ourselves with the data which are furnished us by empiri- 
cism and tradition concerning the antisyphilitic action of mercury. 

1 Several hypotheses have been advanced as to the mechanism of mercurial salivation. 
It was at first maintained that mercury is eliminated by the saliva, its presence determin- 
ing irritation of the gingival mucous membrane. 

Fournier pretends that the initial fact of mercurial salivation is an alveolo-dental 
periostitis, which at its start affects the last molar of the side on which the patient sleeps. 
The salivation is secondary to the outbreak of this periostitis. As for the cause of this 
alveolo-dental periostitis it is believed to depend on a bad state of the teeth or on the local 
action of the mercurial preparations administered by the mouth. (a) 

2 It has been asserted that mercurial preparations have a special action on the 
lymphatic system. Some have affirmed that mercury is a lymphatico-glandular debilitant. 
James Ross, on the other hand, has proved that mercury stimulates the functional activity 
of the lymphatics and this explains the resolvent action of the medicament. Fonssagrives 
takes the same view. 

Mercury, moreover, has, according to the experiments of Rutherford, an action on 
the liver, but while calomel is but slightly cholagogue, the bichloride is much more so. 

Wilbouchewitz, of Moscow has studied the action of mercurial preparations on the 
blood by means of the numeration of the globules. He has always observed that the 
number of the red globules is greater in syphilitic persons during mercurial treatment than 
before; it is the contrary with the white corpuscles. He concludes from this that syphilis 
is the cause of the corpuscular diminution and that mercury by antagonizing this action 
causes the globules to increase. 

In animals under experimentation the administration of mercury always occasions a 
diminution in the number of globules, and this globular deficiency ceases when the use of 
mercurial preparations is abandoned. 

Keyes, in repeating these experiments by means of Hayem's haematimetre, finds that 
mercury in small doses augments the number of globules, but diminishes them in large 



(a) Hallopeau de Mercure (These de Paris, 1878.) 



316 ON THE TREATMENT OF SYPHILIS. 

The absorption of mercury may take place, as I have told you, by three 
ways: by the skin, by the lungs, by the stomach. Therapeutics utilizes these 
three modes of introduction, and thence result three different modes of treat- 
ment of syphilis: the dermic and the hypodermic method, the respiratory 
method, and finally administration by the alimentary canal. 

Let us examine the advantages and disadvantages of each of these methods: 

The dermic method is the most ancient. We have seen that it was by ap- 
plications of mercurial ointment that attempts were first made to cure syphilitic 
sores. This method is still employed at the present day; nevertheless, since 
the improvements in hypodermic injections of our time, the dermic method is 
much less used than formerly. Frictions with mercurial ointment, if they cause 
mercury rapidly to enter the economy, have the very serious objection of 
speedily determining salivation. For these inunctions mercurial ointment is 
used; the "fortior" and the "mitior." The stronger ointment is called the 
Neapolitan cerate. As it is generally admitted that mercury does not penetrate 
the system till it has been subjected to the action of the sudoral secretion, the 
rule has been to practice these inunctions on parts of the skin where the sweat 
glands are the most numerous, as in the arm-pit, the groin, the soles of the feet. 
Denis Dumont has even proposed, under the name of Neapolitan hose, a very 
convenient method for making these applications, especially when the patient 
wishes to conceal the treatment which he is pursuing. This method consists in 
making the patient put on, at bedtime, a pair of hose or long stockings, the 
interior of which has been medicated with Neapolitan ointment. As for the 
frictions, they are repeated once or twice a day, according as one wishes to 
obtain a more or less rapid action. The rubbing lasts from five to ten minutes, 
and when once finished, it is the custom to wash the parts where the inunction 
has been made, to avoid the local irritant action determined by prolonged ap- 
plication of the mercurial pomade. 

Mercurial baths form a part of the dermic method of treatment. Here the 
penetration of the mercury into the system is much less active, and if baths of 
corrosive sublimate render some service in therapeutics, it is simply by their 
local action. These baths, the only mercurial baths employed, contain 3 v of 

doses. Robin has attained the same results, obtaining in patients treated with mercurial 
injections augmentation in the number of globules. Schlesinger's experiments lead sub- 
stantially to the same conclusions. 

Martineau has also noted increased production of globules under mercury; the number 
which is in general from two millions to two millions and a half, went as high as from four 
to five millions, and this chiefly under the influence of subcutaneous injections of 
ammoniaco-mercurial peptones. 



(«) Wilbouchewitz, De C influence des preparations mercurielles sur la richesse du sang en globules 
blancs at en globules routes {Arch, de phys. juillet et septembre, 1874). — Keyes, The effect of small doses of 
mercury in modifying the number of the red blood corpuscules in syphilis; a study if blood counting ivttk the 
haematimetre {American Journal* No. 17, Jan., 1873. — Em. Robin, Recherches sur V influence du traitement 
mercuriel sur la richesse globulaire (these de Paris, 1880). — Schelinger, Experimentelle Untersuchungen iiber 
die werkung lange zeit fo*tge%ebenen kleiner dosen quecksilbers auf thiere(Arch. f. exper. pathol. u. pharmak. 
(Bd. XIII, Hft. 5, p. 347 1 ).— Martineau, Des injections souscntane'es de peptones mercuriques ammoniques dans 
le traitement de la syphilis {Union medicate* 20 aout 1882). 



ON THE TREATMENT OF SYPHILIS. 817 

corrosive sublimate for a full bath. 1 You can add to these baths common salt 
or sal ammoniac. It is also the local effect that is sought for when the various 
mercurial plasters are prescribed, the most known of which is that of Vigo. 

The hypodermic method of the treatment of syphilis is of quite recent date, 
and thanks to the improvements which have been made in the liquids used in these 
injections by Martineau and Delpech, this method, which has all the advantage 
of the dermic mode without the disadvantages, namely, a very prompt and en- 
ergetic action, without salivation, tends to take the place of the dermic method. 
It was Hebra and Charles Hunter who, in 1863, first practiced sublimate injec- 
tions in the treatment of syphilis, and in 1868 Liegeois popularized this method 
in France; but these first trials were unsatisfactory, and the method was aban- 
doned. Corrosive sublimate is in fact very irritating, and it is easy to see that 
these subcutaneous injections, very painful as they are, might cause grave local 
lesions. For the solutions of corrosive sublimate and chloride of sodium, which 
were employed by Hebra, Charles Hunter, Lewing, Liegeois, and Tachard, it 
was proposed to substitute the cyanide or the bicyanide of mercury as Mandel- 
baum and Guntz proposed. Others, as Luton and Fiirbringer, advised injec- 
tions of metallic mercury, rubbed up with glycerine and gum arabic. But all of 
these solutions were always painful, and it was only by combining albumen and 
peptones with corrosive sublimate that solutions were obtained having a very 
feeble irritant action. This is what has been accomplished by Neumann, Bam- 
berger, Terrillon, and especially Martineau and Delpech, who, in uniting chlor- 
ide of ammonium with peptones and with corrosive sublimate, have made a so- 
lution of mercuric ammoniacal peptone which is absolutely neutral, keeps 
perfectly, and rarely determines local lesions when properly injected. 2 

1 The formula of corrosive sublimate baths is as follows : 

1. 

5 Bichloride of mercury, 2 parts. 
Alcohol, 5 parts. 
Distilled water, 200 parts. 



M. 



M. 



M. 



2. 

^ Bichloride of mercury, 3 parts. 
Chloride of ammonium, 3 parts. 
Water, 1000 parts. 



Bichloride of mercury, 1 part. 
Chloride of sodium, 1 part, 
Warm water, 100 parts. 



2 Neumann maintains the advantage of subcutaneous mercurial injections; he lauds 
especially solutions of corrosive sublimate with albumen and peptones as being but slightly, 
if at all, irritating. Bamberger uses the following solution: To 200 cubic centimetres of 
albumen, as pure as possible, add 300 cubic centimetres of distilled water, and filter. Mix 
100 cubic centimetres of this albuminous solution with 60 cubic centimetres of a five-per- 
cent, solution of corrosive sublimate, and 60 cubic centimetres of a 20-per-cent. solution of 



318 ON THE TREATMENT OF SYPHILIS. 

It is necessary, in order to avoid accidents, to make these injections as 
deeply as possible. And here, as in the case of subcutaneous injections of chlo- 
roform, you ought to thrust your needle perpendicularly into the tissues; there- 
fore, it is almost always in the hips that we make these injections. In the 
thousands of subcutaneous injections which Martineau has performed in the 
Hospital of Lourcine, he has never observed any grave accidents. At the same 
time, it is well to remember that in the majority of cases these injections are 
painful, and that they leave behind them an induration of tissue which lasts for 
some time. There are even patients, women especially, so hyperaesthetic that 
they cannot bear these injections. Despite these cases, which are exceptional, 
the hypodermic method is excellent, especially in hospital practice, being sure 
and speedy. In private practice this mode of treatment is more difficult to 

common salt, and 80 cubic centimetres of distilled water. Let it stand two days, and filter 
with care. 20 cubic centimetres of this solution contain gr. ij T 3 o of metallic mercury. 

Terrillon has made trials of hypodermic injections of peptones of mercury. He made 
use of Bamberger's solution, which is as follows: Take of meat peptones, 1 gramme water, 
50 cubic centimetres. Filter; and add: Solution of corrosive sublimate (1:500), 20 cubic centi- 
metres; solution of chloride of sodium (20 per-cent.), 16 cubic centimetres. Distilled water 
sufficient to make 100 cubic centimetres. 

Each cubic centimetre of this solution contains gr. ^ of mercury. In combination with 
peptones, these injections cause no pain, if made deeply in the subcutaneous tissue. 
Delpech has advised the following formula for the preparation of mercuric ammoniacal 
peptones. Take of 

Dried peptone (Catillon), 3 parts. 
Chloride of ammonium, 3 parts. 
Mercuric chloride 2 parts. 
M. 

This powder is one-fourth part corrosive sublimate; hence one gramme contains 25 
centigrammes of corrosive sublimate. From this formula divers preparations are made: 

1. Hypodermic injections — 

]£ Powder of peptonate of mercury, 1 part. 
Distilled water 50 parts. 
Glycerine, 10 parts. 
M. 

Each syringetul of this solution corresponds to gr. I of corrosive sublimate. 

2. A solution which is taken internally — 

5 Powder of peptone of mercury, 1 part. 
Distilled water, 200 parts. 
Glycerine, 50 parts. 
M. 

Each gramme of this solution contains 1:1000 of corrosive sublimate. 

3. Pills— 

5 Powder of peptonate of mercury, 3 ss. 
Opium, grs. viij. 
Powder of guaiac, 3 ss, 
Powder of ext. licorice, sufficient to make 100 pill?. 

Each pill contains gr. ^th grain of corrosive sublimate. 



UN THE TREATMENT OF SYPHILIS. 319 

carry out; you ought then to reserve it exclusively for grave cases, where you 
want a prompt and energetic action, as in syphilis of the brain and spinal cord. 
These injections contain in each syringeful, as you well know, gr. j- of corro- 
sive sublimate. When you do not wish to go to the trouble of preparing the 
rather complex solution of Delpech, you can prescribe subcutaneous injections 

as follows : 

3 Powdered peptone (Catillon), 3 parts. 
Chloride of ammonium, pure, 3 parts. 
Corrosive sublimate, 2 parts. 
Glycerine, 50 parts, 
Water, 150 parts. 
M. 

Each syringeful of this solution contains gr. -J- of corrosive sublimate. 
These injections are practised every day or every second or third day, accord- 
ing to the urgency of the case, and I shall return presently to the doses, when 
I come to the syphilitic complications. 

The respiratory method, which has for its basis mercurial inhalations, is of 
very ancient origin. It has been restored to practice the past few years by 
Langston Parker, of England, by Bumstead, of New York, and by Horteloup, 
in France. This method, which may be called der mo-pulmonary , consists in 
placing the patient in a box in which are burned troches containing cannabar 
or corrosive sublimate. The penetration of vapor is effected chiefly by the 
lungs. The box, being of loose construction, allows the fumes to escape into 
the outside air. I have never employed this afcr^ztf-pulmonary method, but it 
seems to me every way inferior to the hypodermic mode, and is certainly less 
precise and sure. In fact, this kind of treatment is not likely ever to be popu- 
lar. 

I come now to the last method of administration, namely, that by the ali- 
mentary canal, which is by far the most available and practical. Mercury is 
employed under all its forms; ' metallic mercury, the most common preparation 

1 The following are some of the forms of administration of mercury by mouth : 

1. Blue pills. The formula is too well known to need repetition here. 

2. Sedillof s pills . Each pill contains gr. iss of mercurial ointment, with gr. j. of castile 
soap, and gr. \ of licorice powder. 

3. Bichloride of mercury. Van Swieten's formula is as follows: 

1$ Bichloride of mercury, 1 part. 
Rectified spirits, 100 parts. 
Pure water, 900 parts. 
M. 
One teaspoonful contains gr. j Y of corrosive sublimate. 

4. Afauriac's modification of Van Swieten's liquor — 

I£ Spirits of peppermint, 4 parts. 
Hydrarg. bichlorid. , 1 part. 
Alcohol, 95 parts. 
Syrup of morphia. 250 parts. 
Orange-flower water, 100 parts. 
Distilled water, 50 parts. 
M. 



320 ON THE TREATMENT OF SYPHILIS. 

of which is the blue pill; bichloride of mercury, which is the active 
ingredient of the liquor of Van Swieten; the pills of Dupuytren; and the 
ordinary solution of the British Pharmacopoeia; the protiodide (Ricord's 
pills); and the biniodide, which is contained in the syrup of Gibert. These are 
the forms most in use in this country. There are, however, a prodigious num- 

This preparation is twice the strength of Van Swieten's. 

5. Dupuytren 's pills — 

5 Hydrarg. bichlorid., gr. \. 
Ext. opii, gr. \. 
Ext. guaiac, gr. ■§-. 
M. For one pill. 

6. English anti-venereal drops — 

5 Crystallized perchloride of iron, 1 part. 
Corrosive sublimate, 1 part. 
Distilled water, 1000 parts. 
M. 

Every f 3 iij contains gr. \ of corrosive sublimate. A medium dose, one teaspoonful. 

7. Brazilian electuary of Carneiro, containing calomel — 

1$ Calomel, gr. xv. 

Powdered sarsaparilla root, § i. 
Powdered senna, § ss. 

Simple syrup, sufficient to make an electuary. 
M. 

Every f 3 ijss contains gr. jss. of calomel. Full dose, 3 ijss. 

8. Ricord's pills — 

B Hydrarg. protiodid., gr. xlv. 
Ext. lettuce, gr. xlv. 
Ext. opii, gr. xv. 
Ext. hemlock, 3 iss. 
M. F. S. A. 60 pills. 

9. Formula of French Codex — 

5 Hydrarg. protiodid. gr. f. 
Ext. opii, gr. \. 
Conserve of roses, gr. \. 
Licorice root, sufficient for one pill. 
M. 

10. Gib erf s pills of biniodide — 

^ Biniodide of mercury, gr. iss. 
Iodide of potassium, gr. lxxv. 
Pulv. acacia, gr.vijss. 
M. F. S. A. 20 pills. Two of these pills contain gr. \ of biniodide of mercury. 

11. Syrup of Gibert — 

^ Biniodide of mercury, 1 part. 
Iodide of potassium, 50 parts. 
Water, 50 parts. 
Simple syrup, 2400 parts. 
M. Every dessert spoonful contains gr. iv. of biniodide 



ON THE TREATMENT OF SYPHILIS. 321 

ber of hydrargyrate preparations in the shops of pharmacists — pills, solutions, 
potions, pastilles — whose formulae you will find in most of your treatises on 
syphilis. What salt of mercury ought you to choose? It may be replied that 
all the preparations I have just enumerated are suitable. At the same time, for 
my part, I prefer the bichloride and biniodide, to all others, and I consider the 
bichloride, and especially the solution of Van Swieten which contains it, as the 
most active in the first periods of syphilis, of all preparations given by the 
mouth. This preference is not only based on the results of my practice, but it 
is also in conformity with what we know of the introduction into the economy 
of mercury, which always enters the circulation in the state of bichloride. If 
you employ the bichloride, whether in the form of Dupuytren's pills or Van 
Swieten's liquor, I advise you always to administer these preparations with food 
or with milk; you will thus avoid, as far as possible, the irritant local action of cor- 
rosive sublimate on the alimentary mucous membrane. Such are the principles 
of the mercurial treatment of syphilis. I must now point out certain rules 
which should guide you in this treatment — when you ought to commence it, and 
when you ought to leave it off. But before proceeding to this part of my task, 
I must say a few words about the accessory modes of treatment. 

Mercury is not the only metallic substance which has been prescribed for 
syphilis. 1 Chrestein and Legrand have proposed preparations of gold, Serres 
of silver, Hoefer of platinum, and even of copper. All these preparations have 
been successively abandoned, but the treatment which has had the most repute 
is the vegetal treatment. 

The anti-mercurialists, struck by the ravages which mercury occasions, 
had essayed to substitute for it sudorifics, and from the sixteenth century, 
as a result of the influence of Delgado and Ulrich Von Hutten, guaiacum 
was considered as one of the most powerful anti-syphilitic medicines known. 
The success which was then obtained by the sudorific woods depended more 
on the severe regimen to which the patients were subjected than to any 
remedial qualities in the drugs. 

Since then many attempts have been made to return to the vegetal treat- 
ment,'" and numerous have been the compounds of indigenous or foreign herbs 
in decoctions and alcoholic tinctures which have been prescribed, but these 

1 Although Fracastcr made mention of gold in the treatment of syphilis, it is to 
Chrestien, of Montpellier, that we owe the principal indications of this medication. This 
practitioner employed gold in a state of fine division; also the oxide and the perchloride of 
gold and sodium, both internally and externally, in frictions over the base of the tongue, 
etc. Legrand has spoken in high terms of the advantages of this medication, which he con- 
siders as specific in syphilis, (a) 

2 The sudorific or vegetal treatment of syphilis goes back to the i6th century, and 
was especially recommended by Delgado and Ulrich Von Hutten about the year 1517. 
Astruc has given at considerable length the principles of the treatment by guaiacum. 

The decoction of guaiacum was thus prepared: In an earthen pot was infused one pound 



(a) Legrand, on Metallic Gold and its Employ in Syphilis. Paris, 1836. Serres, on the Employment ot 
Preparations of Silver in Venereal Diseases. Hoefer, Gaz. med. de Paris, 1840. 



322 ON THE TREATMENT OF SYPHILIS. 

anti-venereal specifics are utterly unreliable. In Italy, Ubicini Galassi and 
others have experimented with the root of a member of the Cucurbitacecz, viz., 
tayuya. I have not heard of any good results from the medicinal use of this 
plant, and Sigmund and Geher have shown it to be completely inert. Pilocar- 
pine, that powerful sudorific, would naturally have been employed in syphilis, 
and if the sialagogue and sudorific action of a medicament can have any fa- 
vorable influence in the treatment of venereal disease, this alkaloid and jaborandi, 
which contains it, ought to be of efficacy. 3 Notwithstanding the results of 
Lewin, which have not been confirmed by other experimenters, jaborandi does 
not seem to have any curative virtues in syphilis. 

Of this vegetal treatment, nothing remains for consideration but the ptisans 
and syrups called depurative, almost all of which have sarsaparilla for their basis. 1 

of guaiacum in twelve quarts of water; it was boiled down about one-third, or one-half, 
strained, and kept in tight stoppered bottles. 

As for the patient, he was placed in a room which he was not allowed to leave for 
more than a month; was subjected to frequent sweatings by the frequent use of the guaiacum 
infusion, and was regularly purged. He was also kept on spare diet, such as simply bread 
and chicken broth, porridge, etc. 

Many other plants have been employed in the treatment of syphilis, such as aconite, 
hyssop, honeysuckle, burdock, cherry laurel, lobelia, dog weed, persicaria, parsley, soap- 
wort, polygala, and elder, all have had their turn, (a) 

3 Sigmund, of Vienna, and Geber, seem to have effectually disposed of the claim of 
tayuya to the possession of anti-syphilitic properties. 

Lewin has experimented with pilocarpine in the treatment of syphilis, and has obtained 
27 cures in 32 patients (70 per cent.) (The cases were grave.) The mean duration of 
the treatment was 34 days, the whole quantity of the drug employed averaging for each 
patient, gr. 0.372. 

Lewin ordinarily employs pilocarpine in the form of subcutaneous injections in the 
dose of one centigramme (about the one-sixth of a grain), in the case of a woman, and two 
centigrammes when the patient is a man. (b) 

4 Sarsaparilla is a root furnished by several plants of the genus smilax, which grows 
in Central America and South America. Smilax belongs to the liliacese, and the roots 
furnish several sorts of sarsaparillas, which are divided into two groups, the farinaceous and 
the non-farinaceous, according as they do or do not contain starch. The first come from 
Honduras, Guatemala, and Brazil; the second from Jamaica, Mexico, and Guyaquil. 

Galileo Pallotta, of Naples, has extracted from the root a special principle which he 
calls parilline; it is a saponide. On boiling with H 2 So 4 it is decomposed into sugar and 
parigenine. 

[This drug, formerly of much repute in this country, and still occasionally prescribed 
as an excipient of iodide of potassium and other anti-syphilitic medicines, has now almost 
completely gone out of vogue. The same may be said of stillingia silvatica, of which the 
once famous "compound syrup" remains as a medical curiosity. It is doubtful if any 
of the indigenous remedies of this country (and we must here include the much vaunted 
vegetal specific of McDade) have ever cured or benefited a genuine case of syphilis. — 
Trans.] 



(a) Delgado, Del modo di adoperare il legno zancto d" 1 India occidentale^ orvero del modo che si guarise 
il mal grdncioso, e agni male ineurabile, Venise, 1529. — Ulrich de Hutten, De morbi Gallici curatione per 
administrationem ligni guajaci (Aprodisacus, I, p. 275, traduit par Pattern, Paris, 1865). — Astruc, t. II, edit, 
de Paris, Paris, 1777. 

(b) Lewin, Uber die Wirkung dels Pilocarpins im allgemeinen und auf die syphilitischen processe un 
besonderen {Chariti Annal de 1878, Berlin, 1880, p. 489). 



ON THE TREATMENT OF SYPHILIS. 323 

if the vegetal treatment is absolutely without effect, it is not so with the treat- 
ment by the iodides, and particularly iodide of potassium. Since Wallace, of 
Dublin, in 1832, introduced iodide of potassium in the treatment of syphilis, 
this medicine has always been employed in this affection, and if there is still 
some dispute concerning the relative value of the mercurial treatment and the 
iodide treatment, everybody seems agreed in acknowledging the efficacy of the 
latter in syphilis. It has been proposed to substitute bromide of potassium for 
the iodide, and I told you in a former lecture that it was these first attempts in 
this direction that brought the bromide before the profession. During the last 
few years, Garet, taking up anew the former tentatives of Richardson, Magen- 
die, and Gambrini, has counseled the use of iodide of ammonium, but thus far 
iodide of potassium remains almost the sole haloid preparation used. It is 
given in solution, either in water or in syrup of orange-peel. 1 

I have spoken to you many times in the course of these lectures of iodide 
of potassium, and shall not now return to the use of this medicine and 
its therapeutic and physiological effects. I shall only add, that in syphilis 
iodide or potassium may be given in pretty large doses, and we have seen prac- 

1 Gritener was in the habit of prescribing burnt sponge for venereal ulcerations of the 
throat. Martini, of Lubec, in 1821, substituted iodine for the burnt sponge and obtained 
good results. Biett employed in the same year in his service in the Hopital St. Louis, 
iodide of mercury, which Coindet had proposed in 1820. In 1824, Richard de Brus gave the 
tincture of iodine in venereal complaints. In 1831, Lugol reported numerous cases of 
syphilis treated by iodine preparations. 

In 1832, Wallace, of Dublin, was the first to employ iodide of potassium in the treat- 
ment of syphilis. The preparation which he prescribed under the name of mixture of hydrio- 
date of potash, contained two drachms of iodide of potassium in five ounces of distilled water; 
of this solution the patients were to take a tablespoonful four times a day, the equivalent of 
somewhat more than two scruples of iodide of potassium. 

From this date iodide of potassium has been made the subject of clinical experimenta- 
tion in all lands, and its advantages in advanced stages of syphilis have been fully shown. 

It has been proposed to substitute bromide of potassium for the iodide in the treatment 
of this disease; the results have not proved satisfactory. It was thoroughly tested by Ricord 
between the years 1840 and 1850. 

Iodide of ammonium has also been employed by Magendie, Richardson and others. It 
is an excitant of nutrition; given in doses of seven and a half to fifteen grains, it is accord- 
ing to Carat and Druhen, (a) much more active than iodide of potassium in the treatment of 
the tertiary accidents of syphilis. 



(a) Martini (de Lubeck), Hufelnd's Journal, April 1833.— Wallace, the Lancet, March 1836. — Trousseau et 
Pidoux, Traite" de theVapeutique et de matiere medicale, t. ier, p. 267, 3e ddit., Paris. — Ricord, Bull. gen. de 
theYap., t. XII, 1837, p. 241, et Gaz. des hop., 1839. — Payan, Essai thdrapeutique sur l'iode, ou application dela 
medication iod^e ou ioduree, Bruxelles, 1850, et de l'emploi de l'iodure de potassium, Paris, 1847. — Gauthier, 
Observ. prat, sur le traitement des maladies syphilitiques par l'iodure de potassium, Lyon, 1845. — Costilhes. 
Des differents agents therapeutiques employes a Saint-Lazare contre les maladies syphilitiques et de leur ap- 
preciation (Gaz. med. de Paris, 1847, p. 418). — Juda, A practical treatise on urethritis and syphilis, 1836, in-80. 
— Saville, London Med. Gaz., aout 1835. — Bulloch, the Edinburgh Med. and Surg. Journ., January 1837. — Wil- 
liams, dans Syphilidologie de Behrend, t. II, p. 316 et 331.— Gasca, Giornale delle scienze medicne, 1847. — Pe- 
lizzari, GazzettaToscana delle scienze medico-fisiche, 1845. — Gusman, Ledicin Jahrb des OSsterrstaates, 1843. 
— Pourchet, Observation sur l,emploi du brome et de l'hydrobromate de potasse dans la scrofule et le goitre 
(Ephemerides med. de Montpellier, t. VIII, p. 45 a 54, 1828. — Carat, Usage de l'iodure d'ammonium dans la 
syphilis (Gaz. hebd., 1874, no 10) — Druhen, De l'iodure d'ammonium, son emploi en therapeutique dans la 
syphilis et la scrofule (these de Paris, 1875, no 265). — Lancereaux, Traite de la syphilis, Paris, 1866, p. 700. 



324 ON THE TREATMENT OF SYPHILIS. 

titioners like Puche administer from twenty to thirty grammes a day. I do not 
advise you to follow this example, and I believe that generally you should rest 
satisfied with a dose of from two to five grammes (from thirty to seventy-five 
grains), and that it is only exceptionally that you should administer as much as 
ten grammes a day, for in very large doses peculiar toxic phenomena are likely 
to ensue, described under the name of iodism. 

Whenever you give iodide of potassium in massive doses, do not forget 
that you must prescribe at the same time the milk diet. Milk, in favoring the 
elimination by the urine of the iodine, and in preventing the irritant action of 
this salt on the digestive tube, antagonizes the baneful effects of this medica- 
tion. The solution which I advise you to use is the following: 

^ Iodide of potassium, 3 iij. 
Water, § vj. 
M. 

Each tablespoonful of this solution contains just one gramme (fifteen 
grains) of iodide of potassium. 

You should commence with small doses, and when the iodic coryza appears, 
discontinue for several days the use of the medicine, to resume it in larger 
doses. The economy in fact habituates itself to the iodide, and persons who, 
at the commencement of treatment, suffer from irritations of the mucous mem- 
branes as a result of small doses, a little later may bear without inconvenience 
much larger doses of this medicine. 

By the side of these iodine preparations, certain authorities have counseled 
arsenic and sulphur. The first of these has been associated with mercury in a 
compound which enjoys a certain popularity, and which is known under the 
name of Donovan's solution. 1 Ricord has also combined iodide of potassium 
with arseniate of soda. As for sulphur, it has, according to Martineau, a con- 
siderable place in the treatment of syphilis. It is a sort of touchstone, which 
enables us (by the exanthems which it promotes) to determine if the specific 
symptoms have entirely disappeared. 

Such is the therapeutic arsenal from which you may obtain arms to combat 
this disease. But I have accomplished only part of my task in pointing out the 
armor. You must know how to use it. We shall now study in their order the 
treatment of the disease in general, and the treatment of the disease in particu- 
lar, i. <?., in the patient. 

We are chiefly indebted to Prof. Fournier for formulating in a masterly 
manner the general treatment of syphilis under the name of method of successive 

1 Donovan's solution is an iodo-arsenical solution of mercury; the formula, according 
to the U. S. P., is as follows: "Take of iodide of arsenic, red iodide of mercury, each, 
thirty-five grains; distilled water, half a pint. Rub the iodides with half a fiuidounce of the 
water, and, when they have dissolved, add the remainder of the water, and filter through 
paper." 

The dose is from five to twenty drops a day, given preferably in distilled water. The 
dose contains the twenty-fourth of a grain of arsenious acid, a little over the twelfth of a grain 
of deutoxide of mercury, and about a quarter of a grain of iodine. 



ON THE TREATMENT OF SYPHILIS. 325 

treatments. Fournier's system is based on stages of treatment and periods of 
repose, which latter, called by him periods of disaccustoming, 1 enable the econ- 
omy to obtain relief from habits imposed on it by mercurial treatment, and 
derive the utmost possible benefit from the medication during its entire dura- 
tion. So the first year he prescribes for two months the mercurial treatment, 
to be resumed after two months of repose; and this practice is continued with 
similar alternations for two years in such a manner that during the twenty-four 
months the patient will not have been taking mercury but ten months. At the 
end of the second year he administers, concurrently with mercury, iodide of 
potassium, and this latter medicine during the third and fourth years. 2 

Martineau has somewhat modified the formula of Fournier, and, while fol- 
lowing out his system of successive treatments, he gives sulphur preparations 
during the periods of repose. Moreover, these periods, which Fournier has 
traced with great care, must vary according to the patients, and no absolute 
rule can be laid down. I am therefore of the opinion of Mauriac, who advises 
that the treatment should be modified according to the march of the syphilitic 
manifestations. 

Does this method of successive treatments rigorously followed ensure the 
cure of the patient? Unfortunately, no. If, in the great majority of cases, all 
specific manifestations are made to disappear by a well-ordered treatment, 
rigorously followed, nevertheless one can never be sure that the patient is rid 
forever of syphilis, and you will often see arise in patients who have been treated 
with the greatest care, at periods remote from the primary lesion, symptoms 
clearly the consequence of the first infection. This question of the cure of 
syphilis will present itself before you, gentlemen, especially when the marriage 
of syphilitic persons is talked of, and you will be consulted for information as 
to what moment a contaminated individual may marry without danger to his or 
her partner and the children which may be born to this union. Fournier 
has treated this question in an able manner, and has shown that generally you 



1 Stades de desaccoutumance. Fournier, Lecons cliniques sur la Syphilis. 2d ed. 
Paris, 1881. 

2 This is Martineau's process: During the first year he gives mercury for two or 
three months; then he follows it with iodide of potassium for two or three months, then a 
month of rest, and another month of mercury and one of iodide of potassium. 

During the second year he gives mercury for one month and a half, followed by two 
months of iodide of potassium, and two months of rest. He resumes the mercury during 
one month, and iodide of potassium during three months, followed by three months of rest, 
when the patient is subjected to a course of sulphur waters. 

During the third year he assigns a month and a half to mercury and two months to the 
iodide, followed by three months of rest, then one month of mercury, then two months of 
iodide, then three months of rest, during which the patient goes back to the sulphur waters. 

If there are any further manifestations he recommends at the beginning of the fourth 
year, the treatment of the first year, (a) 



{a) Martineau, Lecons sur la Therapeutique de la Syphilis (France Medical, 1882). 



326 ON THE TREATMENT OF SYPHILIS. 

cannot authorize such marriage till after a treatment scrupulously followed for 
three or four years. 1 

Now that we know the duration of the treatment, it remains for us to de- 
termine at what time we should commence it. The sooner the better, say 
Fournier and Mauriac. At the appearance of the first syphilitic manifestations, 
say Sigmund and Zeissl. I believe that the last advice is the safer and wiser. 

The diagnosis of the primitive lesion often presents great difficulties, and 
unless one is an expert and an experienced clinician, it is quite easy to confound 
a hard chancre with ulcerations of quite different nature, and particularly with 
herpes. These difficulties are often such that we see experts, in doubt, practice 
inoculations in order to determine the nature of the ulcerations which they 
have before their eyes. Therefore the practitioner ought to wait for the ap- 
pearance of the roseola to confirm his diagnosis, and indicate the time for com- 
mencement of treatment. When the rash shows itself all his doubts are 
dissipated, and he may begin the administration of mercury. This delay of a 
few weeks is a very little thing in comparison with the duration of a treatment 
which lasts several years, and it has no detrimental influence on the evolution 
of the disease. 

We have already examined two important points in the question of the 
mercurial treatment of syphilis: the duration of the treatment, and the moment 
when it should be commenced. It may now be asked if all cases of this disease 
ought to be treated with mercury and the iodides ? My reply is, Certainly; 
every syphilitic individual ought to undergo the specific treatment. I am well 
aware that in his remarkable work on the Naticral History of Syphilis, Diday 
has shown us that a great many syphilitic patients get well without treatment, 2 

1 This is the way Fournier expresses himself respecting the conditions which a syphi- 
litic patient ought to comply with before thinking of marriage: 

" The essential capital condition to fulfill consists in a thorough specific treatment, 
sufficient to confer complete relative immunity from the multiple dangers which syphilis im- 
poses on the marriage relation. 

For my part, I think myself authorized to say, as a resu t of all my past experience, 
that in no case the duration of an anti-syphilitic treatment should be less than three or four 
years, whatever may be the form of the disease, and however benign in appearance. Three 
or four years methodically devoted to an energetic treatment — such is the minimum neces- 
sary in my opinion, not merely to cure the pox, but to prevent dangerous manifestations in 
the future. 

It is still farther advisable that the patient shall undergo from time to time, every two 
or three years for instance, a new course of treatment by iodide of potassium, in order to 
keep constantly in check the diathesis (if I may so call it), and preserve the benefit which he 
has gained." 

In short, Fournier would deny marriage to every patient not fulfilling these conditions, 
while permitting it to patients who have methodically followed these rules, (a) 

2 Diday has comprehended in five categories the different forms of syphilis classed 
according to their gravity: these forms he has studied in 93 patients : 

1. Cases of minimum severity {syphilis 3auch<?e) — 7 out of 93. As sole manifestation 
the roseola; spontaneous cure without any treatment at the end of two months. 

2. Mild syphilis — 53 out of 93. Roseola, squamae in the palmar and plantar regions; 



(a) A. Fouriner, Syphilis and Marriage. Paris, 1880. 



ON THE TREATMENT OF SYPHILIS. 327 

and I know also that syphilis, like any other disease, has its mild forms and its 
severe forms; and, according to the soil in which it is implanted, it may take 
on a more or less rapid course. But what I am also convinced of is, that we 
often see very grave tertiary symptoms supervene in persons who have had till 
then manifestations of syphilis so benign that this disease has passed absolutely 
unperceived by them. Therefore, it will not do to depend altogether on the 
more or less tardy appearance of the secondary symptoms and their benignity, 
and abandon the specific medication, and in directing this treatment one ought 
to think, not so much of the manifestations he has before his eyes, as of those 
which are likely to appear in the future. 

Finally, to terminate these general considerations on the treatment of 
syphilis, a question remains to be answered: Does the specific treatment cure 
all the manifestations of venereal disease ? Unhappily, no; there is a malignant 
syphilis with galloping march, of ulcerous form, which resists the best directed 
specific treatment. Nevertheless, these cases are exceptional to-day; thanks to 
the hypodermic method, we can master the greater number of specific accidents. 
It is well understood that this treatment will not repair the loss inflicted on the 
tissues by the presence of certain syphilitic neoplasms, like gummata, and when 
these have invaded a part of the cerebro-spinal medulla, the lungs, the liver, 
the pharynx, etc., the specific treatment will be powerless to restore the parts 
thus destroyed. 

These points being duly established, we pass to the study of the syphilitic 
patient, and we will follow, step by step in their progress, the several manifesta- 
tions of syphilis. Let us commence by the chancre. 

The nature of the chancre being once determined, can we, by cauterization, 
or by excision, prevent the system from undergoing the syphilitic infection and 
its consequences ? Such is the first question we have to solve. From data 
furnished by the test experiments of Sigmund, Chadzynski Auspitz, and Mau- 
riac, we are warranted in affirming that the most energetic cauterization and 
even excision made during the first days of the chancre, and before the propa- 
gation of this induration to the neighboring glands, does not prevent the devel- 
opment of the secondary symptoms. I am well aware, according to the 
statistics to which I have referred, that successes have been claimed by both 
cauterization and by excision, but as the failures have always exceeded the 
successes, it may well be asked if, in the latter cases, an error of diagnosis was 



mucous patches two or three days in succession. Cure in ten months and a half, without 
specific medication. 

3. Grave syphilis; erythematous eruption, general debility, ulcerated mucous patches; 
tubercles, osteocopic pains. Necessity of specific treatment. (29 out of 93.) 

4. Galloping syphilis — 4 out of 93. Rapid progress of the lesions, relative impotence 
of the specific treatment. 

5. Tertiary syphilis. The accidents of visceral syphilis. According to Diday only one 
syphilitic in six is likely to have tertiary symptoms. Mauriac finds that this proportion is 
not exact, and according to him the ratio is far less, (a) 



(a) Diday, Natural History of Syphilis.— Mauriac, Lessons on Venereal Diseases. Paris, 



328 ON THE TREATMENT OF SYPHILIS. 

not committed P 1 I believe, then, that this question of the excision of the 
chancre or its thorough cauterization demands new investigation before such 
treatment can be regarded as efficacious. 

The treatment of the syphilitic chancre then consists in local means which 
have for their object to hasten the cicatrization of the sore; a curative pro- 
cess which, by the way, goes on normally with considerable rapidity. Pomades 
of calomel and cold cream (one part to four); lotions of chloral (half per cent); 
light touches with lunar caustic, and, above all, special care about cleanliness, 
suffice generally to hasten the cure of the primitive lesion. Whenever the sore 
becomes deep and anfractuous, and presents a sanious and malignant aspect, 
you can employ tincture of iodine, or, what is better, iodoform. This latter is 
veritably a marvellous medicament in the local treatment of syphilis, and since 
Fereol showed us, in 1868, the happy topical effects of iodoform in chancre, it 
has daily been put in usage and always with success. 2 

You are well aware that of late years iodoform applications have had a 
great popularity, and that they occupy to-day the first rank among antiseptic 

1 Sigmond has furnished the following statistics: 

Number of 

Number of consecutive cases 

cases. of syphilis. 
Patients cauterized from the first to the third 

day after contagion 24 3 

Patients cauterized from the third to the 

tenth day 11 7 

Patients abandoned to themselves 22 11 

To practice this cauterization, acid nitrate of mercury, caustic potash, or saturated 
solution of chloride of zinc are used. 

Chadzynski has thirty times practised excision of the indurated chancre with these 
results: 16 failures, 7 cases doubtful, and 7 cases successful. He thinks that extirpation is 
indicated as prophylactic means in recent cases (two, three, four and five days) and before 
the glands are affected. 

Auspitz has combated this view and maintained that excision has no therapeutic value 
whatever. Mauriac has practiced excision of indurated chancre three times; in one, four 
days after its appearance; in another fifty hours after its appearance; in the third at the end 
of forty-eight hours. In none of these cases was he able to prevent the appearance of 
secondary accidents, (a) 

2 Iodoform was discovered in 1822 by Serullas; its composition was given by Dumas, and 
Bouchardat in 1846 made known its principal therapeutic properties. Since then this 
medicament has been much studied, and it has been bi ought largely into use, in the last 
four years, as an internal and external agent. 

As a local application it is both calmative and antiseptic. In 1853, Moretin pointed 
out the local anesthetic effects of iodoform. Sallier, Besnier, and Demarquay, in 1867, 
demonstrated the good effects of iodoform in the treatment of cancerous sores. Still later 
Fereol communicated to the Society of Therapeutics in 1868 the results which he obtained 
from this medicament in the treatment ot syphilitic sores of bad nature. 






(a) Chadzynski, Sur la valeur prophylactique de l'excision de !a sclerose syphilique initiale (Ann. de 
dermat., 2e serie, vol. Ier, p. 461). — Auspitz, Zur frage der excision der syphilitische initial sclerose (Viertel- 
iahrs. fur Dermat., p. 281, 1800). — Jullien, Traite" des maladies veneriennes, Paris, 1878, et Bull, de Thdrap., t. 
XCV, p. 4Q, 1878. — Mauriac, Traite des maladies veneriennes, Paris, 1883, p. 48. 



ON THE TREATMENT OF SYPHILIS. 329 

dressings. I know of but one objection to this medicinal agent — its disagree- 
able odor. Attempts have been made to mask this odor, but none of them 
have been very successful. 3 It has been employed in pomades, powder, and, 
better still, ethereal solution. Berkeley Hill has proposed a very concentrated 
solution (one part of iodoform to eight of ether). I prefer a very dilute 
(five per cent.) solution, and I apply it to the genitals by means of a spray 
atomizer. You can thus cover the most anfractuous parts of the sore with a 
thin coating of iodoform, and you have often seen in my service the good 
results which we obtain from these ethereal iodoform sprays in the treatment 
of venereal sores in the female. 

It has been proposed to substitute for iodoform, bisulphide of carbon; but 



The following preparations containing iodoform are suitable for external use: 

I£ Iodoform i gramme. 

Glycerine 10 grammes. 

Essence of roses, enough to destroy the odor. 

The following is a good pomade: 

B Iodoform i gramme. 

Balsam of Peru 3 " 

Vaseline 8 " 

M. (a) 

3 Various means have been tried to deodorize iodoform. We have seen recommended 
tonka bean, musk, balsam of Peru, essences of peppermint, lemon, vanilla, etc. Fourmont 
and Sherck have employed carbolic acid, which in minute quantity removes the odor of 
iodoform; camphor does the same. 

The following formulae have been recommended for deodorizing iodoform: 

IJ Carbolic acid (crystallized) 1 gr. 

Iodoform 10 gr. 

M. 

Iodoform 10 gr . 00 

Carbolic acid o gr. 05 

Essence of peppermint 1 to 2 drops. 

M. 

^ Camphor 5 gr. 

Essence of peppermint 2 gr. 

Iodoform 15 gr. 

M. 

J^ Iodoform 100 gr. 

Essence peppermint 5 gr. 

Essence orange 1 gr. 

Essence citron 2 gr. 

Tincture of benzoin 1 gr. 

M. 



The last preparation has the odor of "eau de Cologne." (b) 



(a) Bouchardat, De 1'iodoforme (Journ. de pharm., t. IV, p. 18, et t. XXIII, p. 1). —Ernest Besnier, Sur 
Taction therapeutique de l'iodoforme (Bull de therap, t. L. XXIII. p 493). — Fereol, De Tiodoforme employe 
comme topique pour cicatriser les plaies et ulceres non cancereux (Bull, de therap. t. LXXIV, p. 400, i860). — 
Berkley-Hill, On the therapeutic use of Iodoform (Brit. Med. Journ,, Jan. 1876, p. 127). 

{b) De la deodorization de 1'iodoforme (Journ. des So. Med. de Lille. 21 juin, x^Z-^i. 



330 ON THE TREATMENT OF SYPHILIS. 

the smell of this compound is quite as disagreeable as that of iodoform, and it 
is not proved to have any therapeutic advantage over the latter. 

When once the chancre is healed, and the roseola makes its appearance, 
you begin the mercurial treatment, and I have already told you that, in my 
opinion, the best preparation is the liquor of Van Swieten; and you thus follow 
the various stages of the disease. 1 

1 Syphilis is a constitutional disease caused by infection of the organism by a special 
virus (virus syphiliticus) giving rise successively to divers manifestations which have been 
divided into primary, secondary, and tertiary. 

Syphilis may be hereditary or acquired. In common syphilis the first manifestation 
is a special ulceration called hard chancre, Hunterian chancre, infecting chancre. 

This chancre, which generally appears six weeks after the infection at the point of 
inoculation, is in general solitary, and occasions in the great majority of cases engorgement 
of the lymphatic glands of the vicinity. 

The chancre begins in a little brown papule or in an indolent ulceration or erosion, 
ordinarily about a centimeter in size, with adherent and sloping borders, with smooth, even 
base, of reddish-brown color with grayish serous secretion. The underlying induration may 
be parchment-like, is more apt to be of split-pea variety, or there may be an elevated 
tubercle with a dome-like ulcerated cap. 

The affection of the glands (adenopathy) always follows the infecting chancre. Those 
of the neighboring clustre (glands of the groin) are swollen, movable under the skin and 
upon the deep parts ; they are hard, indolent, non-inflammatory, never spontaneously 
suppurate but undergo progressive regression. After the chancre gets well there is generally 
a period of calm, then after an average interval of forty-five days from the first appearance 
of the chancre (Diday) appear the accidents called secondary, which ordinarily affect the 
tissues in a manner both superficial and benign. These lesions pertain to the cutaneous 
system and its annexes (syphilides, alopecia, onyxis), lesions of the mucous system, mucous 
syphilides, adenopathies, and especially in the female painful phenomena, such as certain 
nervous troubles — divers neuralgias, "vapors," vertigines, hysterical fits, partial contractures, 
palpitations, etc., and general disturbances which may profoundly modify the functions of 
organs (uterine troubles, troubles of menstruation, abortion, etc.) 

The cutaneous syphilides are indolent, apruriginous, affecting divers forms and fre- 
quently characterized by a special brownish or coppery coloration. They manifest them- 
selves over the whole body, often beginning in the hypochondrial regions under the form of 
red spots of an indolent character (roseola) or squamous papules. On the hairy scalp they 
appear in the form of acne pustules which are destroyed by scratching and replaced by 
crusts. This eruption is accompanied by swelling of the post cervical glands. 

Fournier divides the cutaneous syphilides into: 

i. Precocious syphilides (roseola, urticaria, papular or papulosquamous syphilide 
with small papules, and acneiform syphilide of the hairy scalp). 

2. Tardy syphilides, i. e., not appearing till at an advanced period of the second stage 
(pustulo-crustaceous syphilides of ulcerous form, deep ecthyma, rupia). 

3. Intermediate, i. e., not appearing either so early as the first series or so late as the 
second (papulosquamous syphilides with large papules, palmar or plantar psoriasis, papulo- 
crustaceous, herpetiform, acneiform syphilides, superficial ecthyma, pigmentary syphilis). 

The alopecia, the onyxis and the peri-onyxis are secondary accidents, the hairs become 
thin and light and fall out in more or less quantity, but they grow again at a later period 
unless the lesions of the scalp are deep. 

The nails become frail and brittle and peel off; sometimes, on the contrary, become 
thicker and hypertrophied; the borders of the nail may be affected (uperonyxis) or become 
inflamed and ulcerated (ulcerous perionyxis). 

The mucous syphilides present themselves later; they are seated on all the mucous 



ON THE TREATMENT OF SYPHILIS. 331 

You all know that syphilis evolves by stages presenting characteristic 
symptoms, and to which has been given the name of secondary period, transition 
period, and tertiary period. In the secondary period we depend on mercury; 
in the period of transition we give mercury and iodide of potassium together. 
A convenient form of administration is the syrup of Gibert, which contains 
biniodide of mercury with iodide of potassium. 

Lastly, in the tertiary period we use iodide of potassium almost exclusively. 

There has been much discussion as to the precise time when the iodide 

membranes but especially on the buccal mucosa, on the internal aspect of the tonsils, on the 
borders of the tongue, the inside of the labia, os uteri, margin of the anus; they develop 
spontaneously, secrete a virulent liquid, and affect divers pathological forms, hence called 
erosive, papulo-erosive, papulo-hypertrophic, ulcerous, etc. 

To the second period belong also: 

i. Certain ocular troubles, (iritis, ordinarily mono-ocular, keratitis, (rarely) choroiditis, 
retino-choroiditis). 

2. Lesions in the genital regions (syphilitic albuginitis or sarcocele, syphilitic epididy- 
mitis). 

3. Functional troubles of the locomotor apparatus, affecting the bones (peri-ostitis, peri- 
ostasis, ostealgia); the joints (arthralgia and arthritis), the tendons (inflammations and 
dropsies of the tendinous sheaths); the muscles (muscular pains, enfeeblement, tremblings, 
contractures). 

4. Lesions of the nervous system, characterized by headache, neuralgias (facial and 
sciatic), troubles of the sensibility (analgesia, simple or complicated with anesthesia), certain 
paralyses almost always partial (facial, paralysis of the common motor oculi, or of the 
motor oculi externus); sometimes, but rarely, intellectual disturbances, especially in nervous 
women, troubles of caloricity (partial sensations of chilliness, bursts of perspiration). 

The general troubles of the secondary period may pertain: 

1. To respiration (rare). 

2. To the circulation (palpitation). 

3. To the digestive apparatus, especially in females or very nervous men; diminution 
or loss of appetite, exaggeration, perversion of the appetite, enteralgia, icterus. (Ricord and 
Gubler). 

4. To the genital system (uterine neuralgia, menstrual troubles (rare), troubles 
connected with pregnancy, frequently abortion). 

The tertiary period of pox is characterized by accidents which appear at an advanced 
stage of the disease and affect the central tissues and organs in a profound and grave 
manner. 

To this group pertain the affections of the bones, which may sometimes manifest 
themselves in the second stage of the disease, but belong especially to the tertiary period. 

They are almost always accompanied with the pains called osteocopic, more marked 
during the night. These are: 

1. The periostites, peri-ostoses, osteites, eburnated exostoses, hyperostoses, caries, 
and necrosis. 

2. The gummata which form in the subcutaneous and submucous cellular tissue 
acquire a volume more or less large, are indolent or painful and terminate often by softening 
and leave after them grayish excavated, sharply- cut ulcerations. 

3. The deep affections, rupia, deep ecthyma, etc. 

4. The ulcerations of the deep organs, ulcerations which some writers class in a fourth 
period and call quaternary accidents. These are the morbid determinations of syphilis to 
the brain, the lungs, the liver, the spleen, the kidneys, the syphilitic encephalopathies, 
syphilitic phthisis, the parenchymatous and gummy hepatites, the nephrites. 

In the last stage of the disease, in subjects very much enfeebled, whether by the pro- 



332 ON THE TREATMENT OF SYPHILIS. 

should be given. In a recent work, Gougenheim has shown that even in 
the secondary stages of syphilis iodide of potassium gives good results. 
Martineau, in opposition to Zeissl, who would give mercury after the iodide, 
recommends always to precede the iodide treatment by the mercurial, and I 
believe, judging from my own experience, that his views are sound. 2 

There are certain syphilitic accidents of a stubborn kind encountered in 
different periods of syphilis, and which resist to a certain extent the mercurial 
treatment. I refer particularly to the mucous patches that have for their seat 
the vulva, the pharynx, and even the labial commissure. These patches per- 
petuate themselves under the least local irritation. As for those of the vulva, 
you will need to enjoin the utmost care as to cleanliness, and local applications 
of iodoform and ether, or iodoform ointment, will be required; as for those in 
the mouth and throat, you must forbid the patient to smoke, and you will have 
to touch the sores with tincture of iodine or Van Swieten's solution. 

The tertiary complications are often very serious, especially when they 
affect the nervous centres, and urgent measures will be required, such as the 
administration in large doses of mercury and iodide of potassium. Here we 
witness the triumph of hypodermic injections of peptonate of mercury, or fric- 
tions of mercurial ointment, associated with iodide of potassium; and I know 
of no more convincing evidence of the efficacy of this kind of treatment than 
the cures which are obtained in so short a time from cerebral complications so 

gress of the disease or by excess or privations, supervenes sometimes a profound cachexia 
which undermines the constitution. The appetite is lost, the patient grows pale, languishes, 
becomes incapable of any physical or mental labor, and emaciates; ecchymoses form on various 
parts of the body; there is hectic fever, night sweats come on, and the debilitation makes 
rapid progress; the patients fall into a marasmus and succumb. 

Such in our climate is the typical course of acquired syphilis, in its worst phases, and 
apart from a rational treatment. 

2 Gougenheim has shown that iodide of potassium is anti-syphilitic in the secondary 
stage, and he has treated, at the hospital of Lourcine, 220 patients affected with primary and 
secondary manifestations by iodide of potassium, in the dose of one to four grammes per 
day. Of these 220 patients, 144 got well, 32 were very much benefited, and 49 left the hos- 
pital during the course of treatment. 

He made coincidently another series of trials with mercurial treatment, and showed 
that iodide of potassium, administered during the secondary period in doses of 1 to 2 
grammes a day, acts with the same rapidity as the liquor Van Swieten in the dose of 15 
milligrammes (of corrosive sublimate); but that the iodide treatment shows itself inferior to 
the mercurial when the resort is made to hypodermic injections of the sublimate, in doses of 
12 to 25 milligrammes. 

Ziessl is a partisan of the expectant method of treatment of syphilis; only as the symp- 
toms tend to disappear he employs mercurial medication; but before making use of the 
latter, he always gives iodine preparations (protiodide of iron, and iodide of potassium), and 
follows it up for six weeks. Martineau administers iodide of potassium from the beginning 
of the first year of syphilis, and three months after the infection. According to him you 
should always precede the iodide treatment by mercury, (a) 



(a) Gougenheim, De la valeur comparative de la medication iodurique et de la medication hydrargyrique 
de la syphilis, notmment a la periode dite secondaire de la maladie (Bull, et Mem. de la Soc. de ther., 1883, 
P- 97- 



ON THE TREATMENT OF SYPHILIS. 333 

grave that they would have caused the death of the patient in a few days if help 
had not arrived. Paralytic and meningeal symptoms all disappear as if by 
enchantment. 

When lecturing on the treatment of myelitis, I told you of the difference 
which exists between the ataxia of syphilitic origin and other affections of the 
spinal cord due to syphilis; the first being well-nigh incurable despite the most 
energetic specific treatment, the second being amenable to such treatment. 

Mineral waters have an important place in the treatment of syphilis, and 
especially the sulphur waters. Numerous discussions have arisen concerning the 
action of these waters. Some maintain that certain of these waters have anti- 
syphilitic properties; others that they only make known the fact whether the 
patient is cured or not of the syphilis; others claim that these waters have only 
a tonic and stimulant effect. The latter view counts the most adherents, and 
is undoubtedly the correct view. The favorite resorts for syphilitic patients are 
the spas of Aulas, Bareges, Luchon, Cauterets, Amelie les-Bains; in a word, the 
various sulphur springs which abound in the Pyrenees. 

I have finished the general treatment of syphilis, but I desire to say a few 
words about other venereal diseases, viz., the soft chancre and gonorrhoea. 
Soft chancre requires the same treatment as the infecting chancre. At the 
same time, under some circumstances, the soft chancre becomes phagedenic, 
and then it is necessary to employ a very energetic treatment to arrest the 
spread of the ulceration. Therefore, after failure with perchloride of iron, 
iodoform, and tincture of iodine, you may have to resort to cauterizations with 
the hot iron in order to modify the surface of the sore. To all these measures 
we must add partial baths of 40 C, which, according to Aubert, constitute the 
most powerful curative agent in simple chancre and its complications. You 
well know that the mercurial treatment is contraindicated in phagedsena, and 
that it is necessary to employ tonics under all their forms. 

The treatment of gonorrhoea comprises the treatment of blenorrhagic 
urethritis, and that of blenorrhagic vaginitis. In the former, several forms are 
to be distinguished. Either it is a case of acute blenorrhagia, or the disease 
has become subacute, or has passed on to the chronic stage. In acute blenor- 
rhagia, the most rapidly curative medicine is copaiba. You know that this bal- 
sam, which is in reality one of the turpentines, is composed of an essential oil, 
which is eliminated by the lungs, and a resinous copahivic acid, which is elimin- 
ated by the urinary passages, and it is this elimination which is the curative 
agent in gonorrhoea. 1 But in order to obtain from the copaiba treatment 
all the benefits which you expect, you must follow certain rules here laid down. 

1 [The following gonorrhoeal mixtures are from the work of Keyes on Venereal Dis- 
eases. — Trans. 

5, 01. santali § ss-i. 

Liquor potassae 3 ij-iv. 

Syr. acaciae § i. 

Aquae fceniculi q. s. ad § iij. 

M. S. Teaspoonful well diluted, in the third hour after eating. 



334 ON THE TREATMENT OF SYPHILIS. 

Never give copaiba in the first periods of gonorrhoea, when the inflammation is 
invading the entire urethral mucous membrane, for at this stage it is worse than 
useless. Rather wait eight, ten, or twelve days, till this general inflammation 
has subsided, before giving copaiba. During this period you can give the 
diuretic infusions, or alkaline solutions, which have a sedative action. Then 
you can begin with copaiba, which may be given in capsules, dragees, or in 
some of the numerous anti-blenorrhagic compounds, like the famous potion of 
Choppart, which contains copaiba with syrup of tolu and essence of pepper- 
mint. But in whatever form it may be administered, it is necessary to give it 
in frequently repeated doses, so that the urine may be always charged with 
copahivic acid at the time of emission; so when you make use of the capsules, 
you should order the patient to take six of them a day — one every two hours. 
You should increase them by one capsule a day till he takes twelve during the 
twenty-four hours — one capsule every hour during the daytime. This dose 
should be continued for two days; then you can diminish them by one capsule 
a day, till the patient comes to take only one in twenty-four hours, at which 
time the cure ought to be complete. 

In subacute urethral blenorrhagia, you can accompany treatment by co- 
paiba with the use of alterative or astringent injections. 3 I assign due weight, 

1$ Bals. copaibse § ss-i. 

Liq. potassae 3 ij-iv. 

Syr. tolu 1 iss. 

Extr. glycyrrhizse • . 3 ij- 

Aquae menth. pip q. s. ad § iij. 

M. Shake. 

S. One or two teaspoonfuls at a dose. 

^ Bals. copaibae 3 iv. 

Syr. tolu 

Syr. acacias 

Aquae menth. pip aa 3 viss. 

M. Shake. 

S. Teaspoonful. 

2 The astringent injections have for basis sugar of lead or sulphate of zinc or tannin. 
Here are several of them: 

Ricord's injection: • 

IJ Zinci sulphatis 

Plumbi acetatis aa gr. xv. 

Tincture catechu 

Tincture opii aa 3 j. 

Aquae Rosarum 1 vi. 

M. Injection. 

3 Plumbi acetatis gr. ij ad iij. 

Decoction papavaris 1 iij- 

M. 

The above is to be used at night and allowed to penetrate without restraint, as far as 



ON THE TREATMENT OF SYPHILIS. 335 

gentlemen, to all the discussions which have arisen relative to the medicinal 
action of urethral injections, some authorities considering them as beneficial, 
others as dangerous. I believe that they are both, according to the time when 
they are employed, dangerous in the inflammatory periods, beneficial in the sub- 
acute and chronic stages. You are aware of the multiplicity of these anti- 
blenorrhagic injections, which may be divided into three groups: first, those 
that have a modifying action, the type of which are injections containing nitrate 
of silver; second, astringent injections, such as those of tannin and sulphate of 
zinc; and, lastly, the parasiticide injections, which are to-day very much in 

t 
the ordinary impulsion of the syringe will convey it. In four or five days it may be used 
more frequently. Used at the London Lock Hospital. — H. J. Johnson. 

^ Vini rubri ^ vi. 

Acidi tannici gr. xviii. 

M. 

For the male urethra. For the vagina the quantity of tannin may be doubled, or still 
further increased. — L. Parker. 

5 Zinci sulphatis 

Acidi tannici aa gr. ij. 

Aquae I ij. 

M. Injection. To be used repeatedly through the day. — Acton. 

[A highly successful and rational mode of treatment has been lately proposed by Dr. 
Z. T. Dellenbaugh, of Cleveland. Ohio. It is as follows: 

"In cases of acute gonorrhoea I have, for eight or ten years, used carbonate of lithia 
to alkalinize the urine, and find the five-grain compressed tablets, one taken three times 
daily, very convenient, fulfilling every indication better than any other salt. I now rarely 
find it necessary to give any other remedy internally. 

Should the case fail to respond to the following injections, and not show marked 
improvement in two or three days, two sandalwood oil capsules may be given, three times 
daily, for three or four days. The injection I have used in cases of acute and subacute 
gonorrhoea for more than a year with the most gratifying results, especially to the patients, 
who have recovered in from two to seven days, and paid me from one to three visits, is the 
following : 

^ Rescorcin 3 j. 

Acid boracic gr. xx. 

Zinci acetatis gr. %-%. 

Aqua destillat ^ iv. 

M. 

Of this solution two teaspoonfuls are injected three times daily. The germicides, 
resorcin and boracic acid, are so slightly astringent, that it requires the additional zinc salt 
to restore capillary tonicity. This injection is quite or nearly painless. 

In the treatment of the later stage of sub-acute and chronic gonorrhoea, without stric- 
ture or granuloma as a complicating factor, I have had the happiest results follow the use 
of the following injection: 

I£ Hydrarg. chlor. corrosivi gr. %-ss. 

Zinci chloridi gr. ss-j. 

Aqua distillat \ viij. 

M, Sig. — A tablespoonful to be injected well down into the urethra, three times 
daily."] 



336 ON THE TREATMENT OF SYPHILIS. 

vogue, and although the microbe of blenorrhagia has not been found, it is not 
the less true that these injections, and in particular those of permanganate of 
potash, are employed with success in urethritis. 1 I shall only mention the one 
which I use oftenest myself, of which the formula is as follows: 

1$ Tannin . 3 parts. 

Glycerine 100 ' ' 

M. 

In the treatment by urethral injections it is well to insist upon the directions 
laid down by Keyes. 2 The patient should first be required to urinate; the 
injection should be retained for several minutes in the urethral canal, and it is 
necessary that the syringe be in good working order. In my practice, I prefer 
the syringe of Langlebert. As for chronic gonorrhoea, so-called gleet, it often 
presents an invincible resistance to every kind of treatment, and nothing is 
more obstinate than the goutte militaire. You must bear in mind that, as per- 
taining to this incurability, the patient, by his imprudences, plays a more im- 
portant part even than the disease itself. It is also a noteworthy fact that deep- 

1 The anti-parasitic injections have for their type solutions of permanganate of potash. 
Bourgeois proposes the following formula : 

5 Potas. permanganatis gr. i. 

Water § v. 

M. 

Ziessl would use a much more dilute solution, viz., l /^ of a grain of the permanganate in 
about § iij of water, while Weiss would employ as much as two grains of the salt in the 
same quantity of water. 

Chloral injections have been recommended by Pasqua; his formula is : 

T£ Chloral 1 scruple. 

Water 4 ounces. 

M. 

IJ Tannin . . .". 3 parts. 

Glycerine 100 ' ' 

M. 

2 Keyes gives the following directions as to the method of using injections in 
urethritis: The hard rubber urethral syringe knows as No. 1 A, is probably the best. The 
bulb should be short, the tip only should be introduced into the urethra. It is a mistake to 
crowd the conical tip deeply into the meatus. This bruises the canal perhaps as positively 
as does the long nozzle of the old-fashioned syringe. In using an injection, the latter should 
be slightly warmed; with this warm injection the syringe should be filled and all air care- 
fully expelled. The patient now urinates, washing the pus in this way from the inflamed 
surfaces. After the canal is free from urine, the nozzle of the syringe is to be gently intro- 
duced, just beyond the bulbous tip into the inferior angle of the meatus and the two lips of 
the orifice are to be pressed against each other with the thumb and finger of the disengaged 
hand. The lips of the meatus are not to be pressed upon or against the instrument, but 
against each other. Now the canal of the urethra must be very gently distended by pushing 
the piston slowly home; the syringe may be at once removed and the injection retained 
about thirty seconds and then allowed to escape. These motions constitute the whole act 
in most cases. The quantity of fluid held by the syringe is not enough to penetrate into the 
canal farther than the bulb, and in a capacious urethra not so far. There is little chance 



ON THE TREATMENT OF SYPHILIS. 337 

seated ulcerations or even strictures often keep up this urethral running, and 
in these cases the use of the sound or medicated bougies may have a remedial 
effect. 

After the tonic regimen, ferruginous preparations, bromide of potassium, 
sea-baths, or sulphur waters, will give you more certain curative results than 
the urethral injections and balsamic preparations, which are here absolutely 
useless. 

I have not spoken to you of the abortive treatment of this disease, and for 
this reason — I consider it as useless and dangerous. I have been for many 
years, and am still, physician to a certain association of commercial employes, 
and I have observed very many cases of gonorrhoea among them, and I have 
never once witnessed a cure by the injection of strong solutions of nitrate of 
silver during the first few days of the attack. On the contrary, I have always 
observed that whenever this treatment was followed, there was an aggravation 
of the malady. I discard, then, altogether these abortive measures. 

The treatment of blenorrhagic vaginitis ought to fulfil the two following 
conditions: it should modify the surface of the mucous membrane and prevent 
agglutination of the opposing surfaces. Here vaginal tampons and supposi- 
tories are of great utility. Besides the sachets and suppositories so generally 
employed, ointments introduced by special pomade-depositors, devised by Ter- 
rillon and Auvard, are much in fashion. 3 

Tripier has recommended the employ of clay mixed with glycerine. I 
myself am in the habit of using a conical wad of finely-carded cotton wound 
rather tightly, having the form of a speculum, which is introduced into the 
vagina, after being smeared with a suitable pomade. 

of doing harm, therefore, by throwing the injection too deeply down the canal. After 
injections have been used for a time it is allowable to manipulate the fluid in the canal by 
holding the meatus shut with the finger and thumb of one hand while with the fingers of the 
other hand the fluid is pressed forward in the urethra so as to distend it and backward so 
as to make it penetrate more deeply. In so pressing back a fluid the finger should never 
be carried beyond the peno-scrotal angle, or the fluid may be drawn back into the prostatic 
sinus and light up cystitis or occasion epididymitis. A light injection used twice a day does 
more good than a strong injection used only once. The time to use injections with most 
success is when the discharge is on the decline, after the height of the inflammatory 
stage is passed. In cases which commence deep in the urethra, when the meatus does 
not pout, injections may be used from the very beginning of the attack; in other cases it is 
better to wait and not use them at all until the flow has begun to yield to internal medication. 
A good injection to begin with is simple dilute lead water; when a more powerful astringent 
is needed, resort must be had to sulphate of zinc, (a) 

3 The pomade of Terrillon and Auvard is made as follows: 

3 Tannin i part. 

Vaselin 

Starch aa 3 parts. 

M. 

These substances are incorporated into a paste, which is introduced into the vagina by 
the pomade-depositor. This treatment has proved very efficacious. 



(a) Keyes, On Venereal Diseases. Wm. Wood & Co. New York. 
§22 



338 ON THE TREATMENT OF SYPHILIS. 

Apropos of these ointments, there are numerous formulae all having 
for basis substances more or less astringent and antiseptic. Of all these 
preparations that which seems to me the best, is the mixture proposed by Vidal 
of Gurgun balsam and lime-water, in the proportion of one part of 
the former to two of the latter. 1 When this quantity of lime-water is exceeded, 
the pomade becomes too thick, and its application on the cone of wadding is 
rendered more difficult. Using then the preparation above formulated, I smear 
my tampon with it, and leave it in place in the vagina for twenty-four hours, 
and I renew this dressing every morning; when removed, the patient should 
wash out the vagina with a cleansing injection. 

Vaginal injections, like urethral injections, require to be taken with certain 
precautions. The syringe with rubber ball and tubing, called in America the 
Davidson syringe, is preferable to the hard rubber or glass tubes in common 
use; or, what is better still in many cases, the fountain syringe with its appur- 
tenances. The terminal canula should give issue to the fluid by lateral orifices. 

The formulae for vaginal injections are too numerous to be mentioned here, 
and you will find in your special treatises a sufficient number from which to 
select for any occasion. I shall only refer to chloral injections, which I was 
the first to recommend. These are now very much in use, and have often a 
very happy local effect. My usual way of ordering these injections is as fol- 
lows: 

5 Hydrate of chloral, I part. 
Water, 10 parts. 

M. Signa. — Add a tablespoonful of this solution to a quart of cold water for an injec- 
tion. 

Next to these chloral injections, and almost on the same level, I place in- 
jections with resorcin. In my study with Callias, of this medicament, I have 
insisted on the energetic modifying action of this substance on bad ulcerations 
of the genital organs. Leblond and Fissiaux have just repeated these therapeu- 
tical experiments, and with equally good results. I know of but one inconven- 
ience attending these applications of resorcin, it is the high price of the medi- 

1 Gurgun balsam (gurgun oil or wood oil) was first employed in 1838, in the treatment 
of gonorrhoea. Vidal employs the following formulae: 

$ Gurgun oil 

Gum arabic aa 4 grammes. 

Infus. anisi 40 grammes. 

M. 

Sig. To be taken in two doses. 

Mauriac recommends as a useful potion in gonorrhoea, the following mixture: 

5 Gurgun oil 16 grammes. 

Gum arabic 10 

Syrup, acacise 3° 

Peppermint water 5° 

M. 

Sig. To be taken in three doses, (a) 



(a) Leon Duval, on Gurgun Oil, These de Paris, 1877.) 



ON THE TREATMENT OF SYPHILIS. 339 

cament. The injection is made by adding 3 ijss of resorcin to a quart of 
water. Next in importance come the astringent injections, containing tannin, 
rhatany, oak bark, etc. 

I have much more to say respecting the treatment of blennorrhagia, but it 
is time to bring this long lecture to a close; the indications which I have given 
will probably meet the greater part of the cases which will occur in your prac- 
tice. 



PART THIRD 



ON THE TREATMENT OF FEVERS. 



FEVER FROM A THERAPEUTIC STAND-POINT. 

Summary. — Fever — Characteristics of Fever — Animal Heat— Clinical Thermometry — Its 
Importance from the Stand-point of Prognosis, Diagnosis, and Therapeutics — Anti- 
Thermic Medication — Pathological Physiology of Fever — Combustions in Fever — 
Products of Elimination — Phenomena of Combustion — Calorimetry — Theories of Fever — 
Vaso- Motor Theories — Theories of Traube, of Senator, of Marey — Theory of the 
Augmentation of Combustions — Nervous Theories — Calorific Centres — Thermic Nerves 
— Humeral Theories — Pyretogenous Substances — Therapeutical Deductions — Anti- 
thermic Medications — Physical Means — Subtraction of Heat — Cold Baths and Warm 
Baths — Subtraction of Blood — Bloodletting — Medicaments Acting on the Circulation — 
Digitalis^-Ergot — Aconite — Veratrine — Antiseptic Medicaments — Quinine — The Aro- 
matic Series — Phenic Acid — Salicylic Acid — Resorcin — Kairine. * 

Gentlemen: In this last part of my course of clinical therapeutics, I 
propose to consider the treatment of fevers, and the present lecture will be 
devoted to fever from a therapeutic stand-point. Such general considera- 
tions will be an excellent introduction to the study of specific fevers, which 
is to follow, and the utility of the subject will be a sufficient apology for 
the dryness and difficulty of many of the details into which I shall be obliged 
to enter. 

Fever is characterized principally by two symptoms, elevation of the 
bodily temperature and increase of the pulse, the former symptom being re- 
garded of preponderating importance as an essential element of fever, 
especially since the clinical thermometer came into use. The very etymology of 
the word (febris, fever, from fervere "to be hot"), 1 and the common consent 
of the medical profession from Hippocrates and Galen downward, sustain this 
view, and clinical thermometry constitutes, with auscultation and percussion, as 
Jaccoud very properly remarks, the foundation stones of the clinician's arsenal. 

This study of morbid heat plays a preponderant part in diagnosis, prog- 
nosis and even in therapeutics, and physicians everywhere to-day, when they 
would judge of the intensity of a fever, and the effects of their remedies depend 
almost entirely on the examination of the temperature. You know how much 
we consult our clinical charts for daily information as to the fluctuations of the 
temperature, and the care which we take to have them absolutely correct, as 
constituting the basis of our treatment. The series of curved lines which I 
here pass before your eyes, shows you the march of the temperature in 
typhoid fever, in pneumonia, in small-pox, in intermittent fever, etc., and 
familiarity with this manner of registering the progress of the fever will 



1 Fever (febris) comes from the word fervere, to be hot, to boil, ferment, glow; the 
Greeks employed the word IIvp, IIvpErJS, whence the name Uvpe'^is, pyrexia, applied to 
the febrile state. 

Some authorities have thought that this word feber, febris, comes from februrer, to 
purge or to purify, but as Littre has remarked, this derivation is inadmissible. 

343 



344 



FEVER FROM A THERAPEUTIC STAND-POINT. 



enable you to a certain extent, by a sight of these carves, to tell what fever 
the patient has, and what are the chances of recovery. 

Have we not gone too far in this direction and neglected the attentive study 
of the pulse? For my part I am convinced that it is generally best to make the study 
of the pulse and temperature march side by side. If the one furnishes us pre- 
cise information concerning the state of the fever, the other enables us to de- 
termine the condition of the heart and the resistance of the patient. In many 
febrile maladies the heart undergoes profound alterations, which seriously 
modify its function and make our prognosis doubtful if not unfavorable. 

Examine then the temperature, but do not neglect the pulse; study its fre- 
quency, its force, its form. Attempts have been made to establish a relation- 
ship between the pulse and the temperature, and Liebermeister and Lorain 1 



1 Liebermeister's table, establishing the relationship between the pulse and fever, is as 
follows: 



TEMPERATURE. 


PULSE. 










MINIMUM. 


MAXIMUM. 


MEDIUM. 


98.6 F. 


37 


C. 


45 


124 


78 


6 


99-5 F. 


37 


5 C. 


44 


I30 


74 




101.4 F. 


33 


C. 


52 


I48 


91 


2 


101.3 F. 


3S 


5 C. 


52 


l6o 


94 


7 


102.0 F. 


39 


C. 


64 


l6o 


99 


8 


103. 1 F. 


39 


5 C. 


64 


I44 


102 


5 


104.2 F. 


40 


C. 


72 


153 


108 


5 


104.9 F. 


4Q 


5 C. 


76 


152 


109 


4 


105.8 F. 


41 


C. 


66 


l6o 


no 




106.7 F. 


4i 


5 C. 


88 


l6o 


118 


5 


107.6 F. 


42 


C. 


114 


168 


137 


5 



LORAIN'S AVERAGES ARE AS FOLLOWS 

PULSE. 



TEMPERATURE 

99-5 F. 
IOI.3F. 

103. i F. 
104.9 F. 

106.7 F. 



70 

95 

120 

145 
160 



FEVER FROM A THERAPEUTIC STAND-POINT. 345 

have given us precious indications in this regard; but these indications apply 
only to the number of pulsations, and tell us nothing about the volume or force 
of the pulse, which can only be made apparent by the touch and the sphyg- 
mograph. 

I need not insist further on clinical thermometry, it is a subject which be- 
longs to the domain of general pathology and clinical medicine, and I hasten to 
the study of fever, properly so called. 

We have seen that fever is characterized by elevation of temperature; 
numerous theories have been proposed to explain this excessive heat, and in the 
last twenty years more especially works have multiplied on this subject. Not- 
withstanding the patient researches of many experimenters, this great question 
of physiological pathology is not yet completely elucidated, and we are in reality 
reduced to an acceptance of the hypotheses of our predecessors concerning the 
febrile process. 2 Without going very far into the history of the doctrine of 
animal heat and fever, and referring you to the remarkable study of Lorain on 
the "Temperature of the Human Body'' for more exhaustive information, I may 
say that the ancients regarded fever as the result of modifications effected in 
the blood, or of some trouble in the innervation of the circulatory system. We 
find both this humoral and this nervous theory maintained at the present day, 
supported, it is true, on other bases, and by arguments drawn from modern 
physiological experimentation, and it is at the same time difficult to say which 
one of these theories is the more probable. But in order to approach this dis- 
cussion profitably it seems to me necessary to enter here into certain details 
which will enable us to explain the different definitions which have been 



According to Lorain, if the rectal temperature at 37.5 C. (99.5 F.), corresponds to 70, 
each rise of one degree will be accompanied by an increase of 25 pulsations, (a) 

2 According to Hippocrates, and more especially Galen, fever depends on augmentation 
of the heat of the body; the heat is formed in the heart and the blood is the vehicle of it. 
Against this febrile state Galen counsels refrigerant medications, such as ptisans, and in 
particular barley tea, and the usage of cold lotions; these views prevailed without disputation 
till the sixteenth and seventeenth centuries. 

Bellini considers fever as dependent on an alteration of the blood. Sydenham sees 
in it only a movement of nature to expel peccant matters. Stahl partakes of the same 
view. Bcerhaave makes particular account of the pulse, which for him characterizes the 
fever. 

Cullen places the seat of the fever in spasm of the extremities of the small blood- 
vessels. Nietski developes this idea and considers fever as peripheral spasm of the 
vascular system. Frederic Hoffmann has expressed the same notion in saying that fever 
is a spasmodic affection of the whole nervous and vascular system. Todd says that 
fever is an irritation of the nervous system. 

At an epoch nearer our own, Broussais expunged fever from pathology. Fever was 
to him a miraculous product of the imagination of physicians. Boullaud makes of fever 
an angeiotenia, and Piorry, an angeio haemitis, that is to say an inflammation of the walls of 
the blood-vessels. 



(a) Lorain, Temperature du Corps Humain, t. 1, p. 30, Paris, 1877. Liebermeister, Deutsch. Arch, f . 
Klin., Band i, 1866, p. 466.) 



346 FEVER FROM A THERAPEUTIC STAND-POINT. 

given of fever. 1 Does the increase of heat, which is the characteristic of fever, 
result from an augmentation in the combustions of the economy? This is the 
point to be settled. The solution of this problem of physiology has been 
sought in the examination of the urine, of the expired gases, in the state of the 
blood itself, and finally in calorimetry. Let us examine each of these points. 

Till the last few years, there seems to have been general unanimity in the 
affirmation that the ultimate product of organic combustions, urea, augments 
with the temperature in fever patients, and that this augmentation is, so to 
speak, in the ratio of the hyper-pyrexia. The experiments of Moss, Murchison, 
Brattler, Claude Bernard, Hirtz, Catel and Unruh, were regarded as absolutely 
demonstrative. 2 Nevertheless, a more attentive examination of the question 
has shown that this augmentation is only relative, and its reality has been so far 
denied that Charvot has even maintained that there is no relation between the 



1 Numerous definitions of fever have been given, "Fever is a morbid state constituted 
by a variety of functional disturbances, and especially by exaggerated bodily temperature 
and acceleration of the pulse." (Compendium of Medicine.) 

" The words fever, pyrexia designate a morbid state of a certain duration, character- 
ized especially by increase of bodily heat and increased quickness of the pulse," by malaise 
and divers other functional troubles, (Grisolle.) 

" Fever is a pathological state constituted by increase of the organic combustions and 
temperature. This elevation is constant, and invariable to this degree that it serves to 
define and specify the fever. * * * Conversely, every individual whose temperature 
undergoes persistent augmentation, has fever." (Jaccoud.) 

"The best definition of fever," says Prof. (See), "is that which is founded on he 
primordial phenomenon which dominates the entire situation. It is that of Galen: Calor 
prater naturum." 

The most complete definition of fever, and the one most conformable to the results of 
experimental physiology is that of Lereboullet — "Fever is characterized by a notable eleva- 
tion of the temperature of the body, regulated under the influence of the nervous system, 
and is due to an exaggeration of the interstitial combustions, being determined most 
generally by an alteration of the blood." (Lereboullet, Diet. Encyclop., article Fever.) 

2 At the beginning of the researches concerning the elimination of urea in fevers, 
everybody seemed agreed in regarding the elevation of temperature as coincident with 
increased elimination of urea; thus Moss claimed that the curve of urea excretion is 
parallel with that of the temperature. Murchison declared that the temperature rose in the 
ratio of the quantity of urea in excess of the normal. Brattler, going still farther, main- 
tained that one might calculate the temperature by the quantity of urea eliminated and that 
a temperature of 40 C. (104 F.) corresponds to an elimination of 40 grammes of urea (about 
600 grains). Desnos, in his these d'agregation of 1866, admits the complete parallelism 
between the secretion of urea and the elevation of the temperature. 

But since this time, by dint of a more careful examination of the subject, and 
thorough study of the influence of alimentation and the function of certain organs on urea, 
it has appeared to observers that this augmentation does not follow the hyperthermia. 
Charcot and Robin maintained even that this secretion is below the normal during the fever. 
Liebermiester has shown that the augmentation of urea does not exist except in the first 
periods of febrile affections; afterwards this augmentation gives place to diminution. 

However, despite these reserves, and especially as a result of making proper account of 
alimentation, the majority of observers are of the opinion that there is augmentation of urea. 
Claude Bernard acknowledges this augmentation, and asserts that febricitants eliminate on 
an average one and a half times as much urea as persons in the state of health. Senator 



FEVER FROM A THERAPEUTIC STAND-POINT. 347 

production of urea and febrile thermogenesis, and that the theory which 
explains the excessive febrile heat by exaggeration of organic combustion 
is not admissible. On the other hand, Charvot has affirmed that the quantity 
of extractive matters 3 follows with great exactness the thermal curve. 

The views of Charvot have found few partisans, and despite the strong 
facts which he alleges in their support, the majority of physiologists and clini- 
cians admit an exaggeration of urea production during the febrile process; not 
by any means, be it understood, by comparing the figures with those which are 
observed in the case of the healthy and well-fed individual, but with those 
which indicate the quantity of urea voided by persons who are fasting. 

The same discussions which arose with reference to the quantity of urea 
excreted by fever patients have been revived when it has been a question of 
determining by the study of the gases of respiration the modifications which 
are effected in the combustions of the economy, and while Leyden, Silujanoff, 
and Fraenkel affirm that there is an augmentation of carbonic acid, Wertheim 



admits that the combustion of albuminoid matters is augmented during the entire duration 
of fever. Hirtz has found this augmentation in cases of traumatic fever. Catel has arrived 
at the same results. 

In fine, Unruh claims that the total excretion of nitrogen is one and a half times as 
much in the febrile process as in the normal state when the individual is fasting. 

Anstie affirms that the augmentation in the production of urea, does not always 
necessarily accompany febrile phenomena, and he cites a certain number of cases where the 
quantity of urea has been below the normal. According to Zuelzer the sum total of azotized 
excretions is augmented during the fever and diminished during fasting and convalescence. 
The relative proportions of nitric acid and phosphorus during fasting remain in the urine 
in the normal limits of the quantity existing in the muscular substance and in the cerebral 
tissue. According to this experimenter, in the febrile state it is especially the denutrition of 
the muscles which is at stake, and in the state of fasting and of convalescence, that of the 
nervous tissue predominates, (a) 

3 The extractive matters in the urine of febricitants have been especially studied by 
Charvot. According to him, the quantity of extractive matters diminishes in inverse ratio 
to the abundance of urea, so that the curve follows precisely that of the temperature, since, 
according to him, the quantity of urea undergoes a notable diminution in fever. He admits, 
also, a diminution of the solid matters, and in particular, of chloride of sodium. Hcepffner 
arrives at similar conclusions, for, according to him, the curves of urea and of extractive 
matters take altogether different directions, (b) 



(a) Anstie, On tissue destruction in the febrile state and its relations to treatment (the Practitioner, 
March- May, 1874). — Moss, Americ. Journ., p. 384-388, 1861. — Murchison, the Continued Fevers of Great Britain, 
London, 1873.— Brattler, Contributions a l'urologie, Munich, 1858. — Desnos, these agreg., 1866, p. 48.— 
Charvot, Temperature, pouls, urine dans la crise et dans la convalescence de la pneumonic — A. Robin, 
Essai d'urolog-ie clinique. — Senator, Untersuchungen iiber den Freberhaften process und seine Behandlung, 
Berlin, 1878. — CI. Bernard, Lecons sur la chaleur animale, p. 422. — Hirtz, article Fievre, Diet. Jaccoud. — 
Catel, De l'urine dans quelques affections febriles chirurgicales (these de Paris, 1874). — Unruh, Retention des 
mateViaux de combustion incomplete dans la fievre (Arch. f. path, anat., p. 48, 1869). — Zuelzer, Bemerkungen 
iiber einige Verhaltnisse des Stofftreohesels in Fieber und Hungersten (Berl. Klin. Wochens., No. 27, page 
381, 1837). 

(3) Charvot, Temperature, pouls, urine dans la crise et la convalescence de quelques pyrexies 
(these de Paris, 1871, No. 180).— Hcepffner, De l'urine dans quelques maladies febriles (these de Parfs, 1872). 



348 FEVER FROM A THERAPEUTIC STAND-POINT. 

and Senator maintain that there is not this increase, 1 and the later engaged a 
few years ago in a vehement dispute with Pfluger apropos of the experiments of 
Colasanti on this subject. The experiments of Liebermeister seem to me to 
decide this question, and to-day it can hardly be disputed that there exists 
during fever an augmentation in the exhalation of carbonic acid. Only this 
augmentation does not show itself except at the commencement of the pyrexia, 
and does not appear to last as long as the elevation of the temperature. 

The examinations of the gases of the blood which have been made by 
Mathieu and Maljean, while showing us a notable diminution in the respiratory 
power of the blood in febrile animals, would have furnished a powerful argu- 
ment to the opponents of the doctrine of exaggeration of combustions in the 
febrile process, if one did not remember how much the respiratory and circula- 
tory movements are increased in individuals affected with fever. 3 I pass rapidly 
by the other alterations of the blood, alterations concerning which little is 
known, 3 only mentioning in this connection the interesting researches of Prof. 

1 Leyden was the first to remark the increased excretion of C0 2 in fever, which increase 
may attain five per cent. Silujanoff remarked the same increase in animals in which he pro- 
duced septic fever; but we are indebted to Liebermeister for the most precise observations 
in the human subject, from which it is demonstrated that the exaggeration of C0 2 corresponds 
to the rise of the temperature, but does not continue with it, for while the temperature keeps 
elevated, the production of C0 2 decreases. 

Fraenkel and Leyden in their experiments on animals, in which they had determined 
fever artificially, always observed an augmentation in the production of C0 3 ; Wertheim, 
however, claims directly contrary results from his personal observations. 

In his experiments on febrile guinea pigs, Colasanti had noted a large increase in the 
consumption of O, and in the production of C0 2 , but in tabulating his results he made allow- 
ance for the difference between the temperature of his animals at the time of the experiment 
and the surrounding atmosphere; admitting, as he properly did, that the temperature of the 
room exercises a considerable influence on the consumption of O and the excretion of C0 2 . 
Apropos of these experiments a long discussion arose between Senator and Pfluger, the first 
claiming that the correction by Colasanti was inapplicable to the case, the other resolutely 
maintaining that always in fever there is augmentation of oxidizing processes. 

2 Mathieu and Maljean have always noted in fever patients a remarkable diminution in 
the respiratory power of the blood. In animals there is the same diminution. Mathieu 
and Urbian have shown that the proportion of O and C0 2 decreases as the temperature rises. 
Geppert has examined the gases of arterial blood in animals in which he had produced fever. 
According to his experiments, the oxygen is not lowered, but C0 2 diminishes proportionally 
to the elevation of the temperature. He regards this lowering of C0 2 as not the cause, but 
the effect of the fever. 

3 Legerot affirms that the haemoglobin of the "globules does not possess the property 
of fixing oxygen during the febrile process. These globules are rendered incapable of 
administering to the internal combustions. 

Richardson also thinks that the septic poisons prevent the absorption of oxygen by the 
haemoglobin. 

Manassein has observed in the blood of persons affected with fever a diminution of the 



{a) Geppert, Die Gaze des arteriellen Blute in Fieber (Zeitsch . f. Klin. Med., t. ii, p. 355).— Mathieu et 
Maljean, Etude clinique et expdrimentale sur les alterations du sang dans la fievre traumatique et dans les 
fievres en general (Bull, et Mem. de la soc. de chirurgie de Paris, t. ii, 1876). — Mathieu et Urbain, Des gaz 
du sang (x\rch. de phys., 1872). — Du Castel, Physiologie pathologique de la fievre (these agrdg., 1878). 



FEVER FROM A THERAPEUTIC STAND-POINT. 349 

Hayem on what he has described under the name of the " haematic crisis in 
fevers," a crisis characterized essentially by an exaggerated production of 
haematoblasts, coincident with the defervescence of acute diseases, and I come 
to the physical demonstration, the most clear in my own mind, of the augmen- 
tation of combustion in fever. I refer to the application of calorimetry to this 
study. Liebermeister, and his pupil, Kernig, have thus shown us by precise 
experiments, that the febrile individual gives forth more heat than the healthy 
individual. 4 

All these things concur then, as you see, gentlemen, in clearly establishing 
this first point, that in individuals affected with fever, there is increase of 
organic combustions. But this does not suffice of itself to explain the febrile 
process; there must be some disturbance in the regulation and distribution of 
heat in the economy. 

Vulpian has devoted one of the most interesting chapters of his splendid 
work on the Vaso-Motors, to the study of the distribution of heat in the healthy 
individual, and in the febrile individual. He has put in clear light, the capital 
role of the capillary net-work, and the influence of the vaso-motor apparatus in 
the calorification of different parts of the body, showing us that whenever the 
capillary vessels of the skin become contracted, there is an augmentation of the 
central heat with lowering of the temperature, of the skin, and superficial sub- 
jacent tissues; when, however, there is dilatation of the cutaneous and sub- 
cutaneous vessels, we have elevation of the temperature of the skin and sub- 
jacent tissues, and a lowering of the central heat. 5 

It is by virtue of the harmonious reciprocal play of the vaso-motors of the 
central organs, and of the periphery, that man maintains in the normal state, 
and under the influence of divers external influences, his temperature at a 
figure almost unvarying. 

These points being once established, we may now approach the critical 
study of the different theories invoked to explain fever. 

volume of the red globules, while on the contrary, Laptschinsky and Kelsch have found an 
augmentation in their volume, (a) 

4 There are two processes of calorimetry — that by cold baths and by warm baths. In 
the process by cold baths, the water of the bath serves as calorimeter; in the other process, 
the patient becomes his own calorimeter. The experiments of Liebermeister and Kernig 
have shown that in the human organism heat production is in the ratio of the loss of heat. The 
more the loss, the greater the production, and vice versa. It is also proved that a healthy 
man, placed in a cold bath, evolves the more heat the lower the temperature of the bath, and 
that a feverish person radiates more heat than a healthy person, (b) 

5 Vulpian, Lecons sur. 1. appareil Vaso-Motor, Paris, 1875, t. II, p. 188. 



(a) Legerot, Etude d'hematologie (these de Pans, 1874). — Richardson, Some new researches on the 
causes and origin of fever from the action of the septic poisons. — Manassein, De la diminution des dimen- 
sions des globules, Tubingen, 1872. — Kelsch, Contributions a l'analyse pathologique (Arch, de phys., 1875). — 
Laptschinstky, Centralbl., 1874, No. 50. 

{b) Liebermeister, Die Regulirung der Warmebeldung bei den theiren von constanter temperatur 
(Deutsch. Klin., 1875, No. 40). — Kernig, Experimentelle, Beitrage zur Kenntniss der Warmeregulirung beim 
Menschen (these inaug., Dorpat, 1864). 



350 FEVER FROM A THERAPEUTIC STAND-POINT. 

When we take a general survey of all these theories, we see that they may 
be grouped in three principal classes. 

In the first class we have the theory of Traube and Hueter; a theory which, 
while denying all augmentation in the combustions of the economy, explains the 
febrile process by modifications effected in the capillary net-work. 

In the second class, the increase of combustions is admitted, but as an ele- 
ment absolutely secondary, the principal role being assigned to the vaso-motors; 
this is the theory of Senator and Marey. 

In the third class the augmentation in the combustions constitutes the 
dominant principal fact, and according as this increase is explained by a trouble 
in the regulation of heat production, whether by the influence of certain parts 
of the nervous system, or by the modification in the vaso-motors, we have the 
respective theories of Liebermeister, Claude Bernard, and Vulpian. Let us 
examine each one of these theories. 

Traube rejects absolutely the notion of augmentation of combustions, as 
explanatory of the thermal elevation, which results, he thinks, from the fact that 
in the period of rigor or chill, the capillaries of the periphery contract under 
the influence of the vaso-constrictor nerves, and the afflux of blood to the cen- 
tral organs becomes the sufficient and sole cause of the febrile manifestation. 

Hueter has gone still further in this direction. Taking his stand on the 
experiments of Albert, which go to show that the mechanical arrest of the cir- 
culation in a vascular tract produces thermal elevation and fever, he maintains 
that the first cause of the febrile process is a mechanical arrest, by embolic 
infarctions, of the capillary circulation of the lungs and skin. 1 

These theories raise so many criticisms and objections that they have been 
virtually abandoned. In fact, they can give no explanation of the rise of 
temperature which precedes the chill in intermittent fever, and they have no 
sufficient application to continued febrile processes. 

The theories of Senator and Marey are much more seductive; in that of 

1 Albert claims for his experiments a demonstration that arrest of the circulation in a 
vascular district causes elevation of temperature and fever; the arrest being the result of 
emboli, which may be purely mechanical, producing fe.ver of an intermittent type, or 
septic, with fever of a continued type. 

According to Hueter, fever is due, not to over-production of heat, but to lessened 
distribution. The body has two surfaces of refrigeration, the cutaneous surface and the 
pulmonary surface. The less the quantity of blood flowing through the vessels of a refrige- 
rating surface, the less the loss of heat, and the greater the general temperature. In fever 
there is arrest of the circulation in these two refrigerating surfaces, and fever ensues, with 
tumefaction of the spleen, kidneys, and liver. All of Hueter's experiments were made on 
frogs. 

Senator has examined the auricular vessels of albino hares in health and in fever, and 
has shown that during febrile heat there is no permanent paralysis or tetanus of the vessels. 
He thinks that the theory of Hueter is not well founded, (a) 



(a) Albert, Untersuchungen iiber das Fieber (Ber. der natvrwiss. Med. Veruns zu Innsbruck, 1873).— 
Hueter, Ueber den Kreislaufund die Krieslauffstcerungen in der Froschlunge versuche zur Behandlung einer 
mecanischen Fieberlehre (Centralb., No. 5, 1873).— Senator, Weitere Beitrage zur Fieberlehre (Centralb., No. 
6, 1873, P- 8 4)- 



FEVER FROM A THERAPEUTIC STAND-POINT. 351 

Senator we find the same explanation as that given by Traube of the mechanism 
of the chills and the totality of the febrile phenomena, but he admits the aug- 
mentation in the combustions of the economy resulting from the enhanced 
destruction of albuminoid matters. 1 

The theory of Marey is very much like that of Senator, but to the initial con- 
striction of the capillaries of the periphery, cause of the central thermal eleva- 
tion, there succeeds, according to him, a paralytic dilatation of this capillary 
net-work, which brings the heat to the surface, "leveling down the temperature." 
In the theory of Marey, as in that of Senator, there is augmentation in the 
combustions, but this is a secondary matter, the primordial phenomenon and 
the most important is the trouble brought upon the vaso-motor circulation of the 
periphery, whether by spasm, as Senator thinks, or by alternations of spasm and 
paralysis, as Marey thinks. 2 

These theories which are much nearer the reality, do not at the same time 
give us a sufficient explanation of the elevation of temperature which precedes 
the chill, and the only theory which is in harmony with all the facts, is in my 
opinion that of Liebermeister. According to Liebermeister, the augmentation 
in the combustions plays the principal part; it is admitted without dispute, and 
you have just seen upon what solid proofs it rests. But it is not enough to 
admit the fact of increase of combustions; the original cause demands explana- 
tion, and here certain opinions come in which we must discuss. 

Just here Liebermeister, to whom we owe such important works on this 
part of general pathology, has furnished us precious data. After having shown 
us by the examination of the urine, of the expired gases, and especially by the 
application of calorimetry, that there is augmentation of heat-production in 
fever, he has well brought to light this other fact that this elevation of itself 
does not constitute fever, and there is needed besides a modification in the 
regulation of heat. Let me explain. 

In the healthy and normal state of man, you may by artificial processes 
raise the internal temperature, but as soon as those means cease to act, the 

1 According to Senator the febrile elevation is due (i) to exaggeration of heat-produc- 
tion, arising from increase of interstitial combustions; (2) to retention of heat, by contraction 
and shrinkage of the cutaneous arterioles. Buss adopts the theory of Senator in explanation 
of fever, which he considers as essentially constituted by a disorder in the deperdition 
of heat. This disorder is attributed to the presence of irritant agents in the blood which 
determine the contraction of the peripheral vessels, and hence, augmentation of heat in the 
ratio of the lessened deperdition. (a) 

2 Marey. Medical Physiology of the Circulation of the Blood. Paris, 1883. 

The important part of Marey's theory is the leveling of the temperature, which de- 
pends on a paralytic dilatation of the peripheral capillaries. At the commencement of the 
attack and during the first period, there is constriction of the capillaries of the periphery; 
the blood is forced into the viscera, and the central temperature rises. Then the cutaneous 
capillaries dilate, and the blood, at a high temperature, flows to the peripheral parts and dis- 
tributes its heat. 



(a) Senator, Untersuchungen iiber den Fieberhaften process und seine Behandlung (Berlin, 1873). — 
Buss, Ueber wesen und Behandlung des Fiebers (Stuttgard, 1878). 



352 FEVER FROM A THERAPEUTIC STAND-POINT. 

temperature invariably falls back to 98%° F. In the fever patient, on the con- 
trary, the loss as well as the production of heat is regulated at an abnormal 
standard, varying according to the malady and the individual, insomuch that, 
according to Liebermeister, the very essence of fever consists in a regulation of 
thermogenesis for a temperature more elevated than normal. 1 

But to maintain that heat production in fever depends essentially on heat- 
regulation is not to solve the problem, but simply to remove it farther back. It 
becomes us now to ascertain what causes this modification in the mechanism of 
regulation. Here comes in the influence of the nervous system, and we have to 
consider what may be called the nervous theories of fever. Claude Bernard 2 
in analyzing the phenomena which occur after section of the great sympathetic, 
was persuaded that there exist thermic nerve fibres possessing a special physio- 
logical function with reference to calorification, and placed under the depend- 
ence of the sympathetic ganglia. The great sympathetic becomes thus the 
moderating mechanism of the chemical combustions of the economy. So when- 
ever the functions of this system are enfeebled, the inhibitory check ceasing to 
operate, the temperature rises; in a word, fever is only one of the manifesta- 
tions of paralysis of the great sympathetic. 

Since Tscheschichin as a result of his curious experiments on the meso- 
cephalon of rabbits, claimed this part of the nervous system as the regulator of 

1 Liebermeister begins by establishing that the temperature of a fever patient is higher 
than that in a healthy person, and that a great part of the symptoms of fever are the conse- 
quence of elevation of temperature; then he shows that in fever there is augmented heat- 
production. Both thermometric elevation and increased thermogenesis are present. 
In the well man every artificial elevation of temperature disappears rapidly, for in the nor- 
mal condition the production of heat is regulated for a temperature of 98^° F. In fever, on 
the contrary, the regulation is adjusted to a certain degree of temperature, which varies ac- 
cording to the intensity of the fever, and its nature, so that the essential difference between 
a fever patient and a well person is this, that in the fever patient the loss as well as the pro- 
duction of heat is regulated by the standard of a high temperature, while in the healthy man 
it is regulated at 98^° F. (a) 

2 Claude Bernard was the first to put forth the hypothesis of the existence of nerve 
fibres, influencing physico-chemical operations and heat production. He showed first that 
section of the sympathetic augments calorification, without increasing the organic combus- 
tions. There is, according to him, a physiological function of calorification, and this func- 
tion is under the control of nerves belonging for the most part to the sympathetic. Inde- 
pendently of its vaso-motor action, the sympathetic has a thermic action. " Its excitation 
produces a frigorific effect; its section or paralysis, a calorific effect. It is not only a vaso- 
constrictor nerve, it is a frigorific nerve." The sympathetic acts then on the physico-chemi- 
cal phenomena, which engender heat, as a sort of moderator, as a check, or an agent of 
inhibition. " It cools the parts which it innervates," he says, "hence the name we give it of 
frigorific nerve. It constricts the vessels, and thus renders the organs pale and exsanguina- 
ted, whence its name, vaso-constrictor. It moderates and slows nutritive movements; it 
merits the name of check, or inhibitory nerve {nerf refrenateur). 

Fever then, according to Bernard, is a result of paralysis of the great sympathetic, {b) 



(a) Liebermeister, Uebor Warmeregulirung und Fieber (Somml. Klin. Vortr. von Richard Walkmann, 
no 19, 1871). 

(3) Claude Bernard, Lecons sur la Chaleur Animale, Paris, 1884. 



FEVER FROM A THERAPEUTIC STAND-POINT. 353 

the combustions of- the economy, making the pons Varolii the heat centre, there 
has been a tendency to consider the thermic elevation of fever as depending, 
not so much on a disturbance in the function of the great sympathetic, as in 
that of the annular protuberance. Vulpian rejects both the theory of Claude 
Bernard, and that of the Russian physiologist. In his opinion, it is not proved 
that thermic nerve. fibres exist, or even moderating centres of thermogenesis; no 
matter in what part of the cerebro-spinal axis you may locate those centres. 1 
According to Vulpian, disturbances occasioned in the vaso-dilators and vaso- 
constrictors, whether by direct irritation of these nerves, or by irritation of the 
spinal cord and of the medulla oblongata, or whether by reflex action, suffice to 
explain the thermal elevation. It is then by modifications effected in the action 
of the vaso-motor nerves that he would explain the febrile process. At the 
same time he recognizes that in many cases the starting point of these troubles 
is in the blood, and this leads us to study the action of alterations of the blood 
on the production of fever; and to the nervous theories of Claude Bernard, of 
Tscheschichin, 2 and of Vulpian, we will now oppose the theories called humoral. 

1 Schiff has made experiments to determine the influence of the vaso-motor system on 
the activity of thermogenesis. He cuts the principal nerves of an animal on one side; then 
he lets the wound cicatrize. Then he determines septic fever in the animal, by injecting 
putrid substances in the blood. On examining the temperature of the members, he finds 
that it is higher in the side where the nerves were not cut. Vulpian repeats the experiments, but 
with contrary results. At the same time he believes in the influence of the vaso-motors, though 
not claiming to give a very complete explanation of the mechanism of heat regulation. "We 
must admit," he says, "that the nerve centres, irritated by the morbific cause, act upon the ves- 
sels to provoke a constriction or dilatation; they determine a constriction of the cutaneous 
vessels in the period of chill . They produce without doubt a dilatation of the deeper vessels, 
especially of the viscera, even during the chill and thus contribute to energize the physico- 
chemical acts, which give rise to heat. But it appears to me incontestable that all is not 
limited to a direct influence on those operations, by the medium of the vaso-motor apparatus. 
The nervous centres must act more directly on those physico-chemical phenomena 
by the fibres of the nerves of animal or organic life which are in more or less im- 
mediate relation with the anatomical elements, the organized, living, protoplasmic sub- 
stances of the different tissues. We must, in fine, admit that morbid causes (pyretogenous 
agents) may act also on this organized substance, modifying the nutritive, calorifacient pro- 
cesses in a manner quite direct, and consequently without the necessary intermediation of 
the nervous system, (a) 

2 Tscheschichin cut the pons, in hares, just before the point where the medulla oblon- 
gata terminates; the rectal temperature rose several degrees, and the respirations were 
markedly quickened. If, on the contrary, the bulb or the cervical cord were sectioned, the 
temperature fell. Hence he considers the pons as acting on the rachidian bulb and spinal 
cord as a centre which regulates and moderates the organic combustions. If you take away 
the curb by cutting the connections between the pons and the medulla, the combustions ac- 
quire a greater intensity. 

Experimenters who have repeated these experiments have not all arrived at the same 
results; some, as Pochoy, obtaining just the opposite results. Moreover, Naunyn and 
Quincke in sectioning the cervical cord in dogs, have obtained elevation of temperature, and 
clinical observations in contusions of the cervical cord by fractures, etc., have often demon- 
strated the existence of hyperpyrexia. In a case of fracture of the 6th cervical vertebra, 



(«) Vulpian Lecjons 1, Appareil Vaso-Moteur, 1875, t II, p. 265. 
§23 



354 FEVER FROM A THERAPEUTIC STAND-POINT. 

There is no doubt that the blood plays an important part in the production of 
the febrile process, and here physiological experiments as well as clinical re- 
searches show us the reality of this action. It suffices, in fact, as you well know, 
to inject into the blood of animals a very small quantity of septic matter, to de- 
termine in them a febrile state, more or less intense, and it is this very process 
which we employ in our laboratories to obtain experimental fever. It is the 
same with man, and the chill, often so violent, which supervenes in patients after 
surgical operations or confinement, is a proof that the blood has been contaminated 
by putrid matters. I showed you when speaking of transfusion, that in many 
cases this operation has been followed by rigors and veritable attacks of fever. 
It is to the same cause, that is, to the presence of particles foreign to the blood, 
that we must attribute these symptoms. Does the trouble consist in modifica- 
tions of the fibrine of the blood, which, analogous to processes of fermentation, 
induce changes in the constitution of that fluid, or does the trouble consist, as 
Verneuil thinks, in the presence of a definite morbid principle, sepsine? Or 
does it consist in the introduction of organized microbes, microbes, which, since 
the discoveries of Davaine and Pasteur, have so considerable a part in our in- 
fectious diseases? These are questions which are not completely solved, but 
there none the less exists this fact which we should keep in mind, that there are 
substances which, introduced into the blood, are capable of determining the 
febrile process and to which we may give the name of pyre 'tog eneous. 

Have these pyretogeneous substances a direct action on heat production, 
or is this action only indirect and secondary, and brought about through the 
intermediation of the nervous system? Without being able to solve this ques- 
tion by precise experiments, I believe that in many cases this action must be. 
secondary, and that it is by modifying the function of the vaso-motor centres 
that in all probability, alterations of the blood determine the elevation of tem- 
perature of fever. 

As you see, gentlemen, of all the theories which I have made to pass be- 
fore you, that which seems to me most comfortable to the facts of clinical med- 
icine and experimental pathology is the theory which makes febrile thermo- 

Frerichs noted a rectal temperature of 43. 8° C. Brack and Gunther in the mechanical irrita- 
tion of the medulla oblongata or pons, determined an elevation of temperature, instead of a 
lowering, which they should have obtained if the hypothesis of Tscheschichin had been cor- 
rect. Electric irritation of these parts by Heidenhain, also gave elevation of temperature. 
Hence Heidenhain rejects the hypothesis of a heat-moderating centre, and Vulpian and 
Riegel share the same opinion. Murri rejects also the nervous theory of fever, claiming 
that the excessive thermogenesis results from a trouble in the physico-chemical process of the 
living elements of the tissues, and not from any special influence of some nervous centre 
which regulates heat production in the economy, (a) 



0)Tschechichin, Zur Lehre von der Thicrischen Warme (Reichert's und die Bois-Reymond's Arch. .1866) 
— Pochoy, Recherches experimentales sur les centres de temperature (these de Paris, 1870, no 120, p. 24). — B. 
Naunyn et Quincke Rechert's und du Bois-Raymond's Aach., 1869.— Riegel, Uber den Einfluss des centrals- 
servensystems auf die Thierische Warme (Pfliiger's Arch., 1871-1872, p" 629-672).— L. Bruck et A. Giinter, Ver- 
suche iiber den Enfluss der Verletzung gewisser Klirntheile auf die temperature des Thierkopers (Pflager's 
Arch., 1870, d. 578-585). — J. Schreiber, Uber den Einfluss dec Gehirns auf die Kurpertemperatur (Pfliiger's 
Arch., 1874, t. VIII, p. 576),— Vulpian, Lecons sur l'appareil vaso-motor, t. II, p. 250, 1885.— Murri, Salla teoria 
della febbre, Florence, 1874. 



FEVER FROM A THERAPEUTIC STAND-POINT. 355 

genesis depend on a trouble in the functionating of the vaso-motor system, 
whether that trouble be primitive or secondary. 

These details being once clearly understood (and you will pardon me for 
having given so much space to their exposition), we can now approach the 
study of the action of medicaments which combat the febrile process and its 
principal characteristic, excessive heat-production; in a word, we will examine 
the bases of the antipyretic treatment. But I must first of all show you the 
necessity of this antithermic medication, in pointing out the dangers which 
hyperpyrexia causes. 

Here, moreover, we were indebted to Leibermeister for valuable data. 1 
Establishing himself on experimental facts and clinical observations, he has 
assigned to excess of temperature a series of alterations having especially to do 
with granulo-fatty degenerations of the different viscera, the most important of 
which, surely is that which affects the cardiac muscle. 

I fear that we have gone a little too far in this direction. Remark, first of 
all, that from an experimental point of view it is difficult, even grounding our- 
selves on the experiments of Liebermeister, to compare an animal in which the 
temperature has been made to rise by artificial means, with a person in whom 
the heat excess is the fact of a febrile process. Moreover, as Hayem has well 

1 The disorders determined by hyperthermia have been studied experimentally and 
clinically. Claude Bernard has shown that in pigeons death ensues whenever the central 
temperature attains 48 C. (118 F.). In mammals death takes place when the temperature 
is 44 or 45* C. (111° or 113 F.); it seems then demonstrated that death always happens 
to an animal whenever the temperature of the blood exceeds the normal by from 12° to 15 . 

In some experiments on dogs Vallin divides into three periods the accidents which 
supervene in animals whose temperature has been abnormally raised. 

In the first period there is acceleration in the respiratory movements. In the 
second respiration becomes sighing and prostration is marked. In the third convulsions 
supervene, and death ensues when the temperature attains 44. 4 C. (112 F.) 

The lesions determined by hyper-thermia, according to Liebermeister, are character- 
ized essentially by a granulo-fatty degeneration of the different viscera; the liver presents 
the lesions of acute yellow atrophy; the kidneys, especially the cortical substance, are 
degenerated. The heart presents notable disorders; it becomes soft and friable, and the 
fibres are affected with granulo-fatty degeneration. 

The lesions observed by Stokes and Hayem in typhus and typhoid fever, by Desnos 
and Huchard in small-pox, and by Vallin in marsh fevers, are all the consequences of this 
hyper-thermia; it is the same with the lesions of the muscles described by Zenker and the 
symptomatic myosites observed by Hayem. 

At the same time the latter considers these myosites, not as the result of hyper- 
thermia, but as the consequence of the infectious diseases which modify profoundly the 
nutrition of the muscular fibres, and this view seems confirmed by a curious observation 
of Vallin, who in a typhus patient, whose temperature never exceeded ioo° F., observed 
fatty degeneration with rupture and hemorrhage of the muscles of the abdomen and thigh. (a) 



(a) Claude Bernard, Influence de la chaleur sur les animaux (Rev. dee cours scient., 1871, p. 134). 
—Vallin, Recherches experimentales sur l'insolation et les accidents produits par la chaleur (Arch. gen. de 
med.., 1870, p. 138). — Liebermeister, Uber die Werkungen der febrilen temperatur (Deutsch. Archiv, Bd. 1, 
1866). — Stokes, Traite" des maladies du cceur et de l'aorte, Paris, 1864. — Hayem, Etudes sur les myosites 
symptomatiques (Arch, phys., 1870). — Desnos et Huchard, Des complications cardiaques dans la variole, Paris, 
1871.— Vallin, De la myocardite et de la myostite symptomatique dans les fievres palustres graves (Un. med., 
1874).— Du Castel, Des temperatures elevds dans les maladies (these d'agregation, Paris, 1875). 



356 FEVER FROM A THERAPEUTIC STAND-POINT. 

remarked, and as the interesting researches of Vallin show, this alteration of the 
viscera, and especially these symptomatic myosites may depend, not on the 
thermogenesis, but (with more likelihood) on the infectious or septic agent, 
which, in altering the blood, has profoundly modified the nutrition of the 
muscular fibre. 

But while combating the exclusive view of those who ascribe to the hyper- 
pyrexia alone the dangers resulting from divers malign febrile processes, I 
recognize the fact that we ought as far as possible to endeavor to bring back to 
the normal the temperature of fever patients. To accomplish this we should 
put in operation the various agencies which constitute the anti-febrile medi- 
cation. 

These medicinal agents may be divided into two principal groups. You 
will see that this division is based entirely on the physiological deductions, to 
which we have given development while discussing the pathogeny of fever, and 
you will at once comprehend how important it was to dwell minutely on this 
part of our subject. 

In the first group we place all remedial measures calculated to remove 
from the economy the excessive heat; we do not attack the causes of febrile 
thermogenesis. This group comprehends refrigerants. 

The second group comprises methods and medicaments which combat the 
cause of hyperpyrexia. Since the cause of the exaggeration of physico-chemical 
phenomena depends, as we have seen, on the two following factors — modifica- 
tions of the nervous system and modifications of the blood, we may range in 
two sub-divisions the medicaments which constitute the second group; in the 
first are those which modify thermogenesis by action on the nervous system, in 
the second those which are antipyretic by direct action on the blood. There 
may even be a mixed third group consisting of medicines which, like quinine, 
belong to both divisions. 

This classification being admitted, we may rapidly go over each of these 
groups, taking only a cursory view, and reserving the more complete details 
which belong to the application of the different therapeutical agents for the 
study of specific fevers which is to follow. 

I. The anti-thermic methods by abstraction of heat have acquired in these 
late years a great importance, especially since the promulgation of Brand's 
experimental researches. Although Hippocrates and Galen 1 have in many 

1 Hippocrates and Galen applied baths and affusions to the treatment of febrile dis- 
eases; one may judge of the estimate in which they held them by the following aphor- 
isms: "A fever which does not come from bile gets well under abundant affusions of 
warm water upon the head," (Aphorisms, sec. 7, §42). "If the patient is delirious make 
affusions upon his head," (Epidemics, book III. Sec. 5, page 49). Galen is quite as 
affirmative; he treats fever by warm or cold baths and by cold drinks internally. 

Rhaz6s advised to combat the fever of small-pox by baths and cold drinks. All 
these facts had, however, been forgotten and abandoned by the followers of Hippocrates 
and of Galen; and we have to come down to the end of the eighteenth century to see 
James Currie, a Scotch physician, practising at Liverpool, establish, on new bases, the 
treatment of fever by cold water. It is thus that James Currie combated what was then 
described under the name of grave contagious fever or "typhus," what we now call 



FEVER FROM A THERAPEUTIC STAND-POINT. 357 

places insisted on the employment of cold, internally and externally, in the 
treatment of fevers; although Rhazes called attention to cold baths as beneficial 
in small-pox, it is certain that these precepts had fallen into desuetude and 
oblivion, and we have to come down to the end of the eighteenth century to 
find the remedial value of cold water in fevers recognized, and James Currie 
proclaiming a new method of treatment of pyrexias, namely by cold baths. 
Currie aimed to obtain, it is true, by his cold applications, not so much a lower- 
ing of heat as a tonic and reconstituent effect. Despite the great efforts of the 
Scotch physician, his mode of treatment was little followed, if at all, and despite 
attempts renewed since in France, by Jacquez, Wanner, Leroy, to treat fever 
by external cold, this practice was virtually abandoned. It is then in reality to 
Brand that we are indebted for the revival and formalization of this ancient 
method. 

I do not mean here to decide concerning this therapeutic measure, or 
estimate its results; such actual examination I shall make in another lecture, 

typhoid fever, and even intermittent fevers. Currie examined the results of his medica- 
tions by means of a thermometer which he placed in the mouth and armpit of the patient. 

He employed cold affusions, i. e., with water at 15 C. (59 F.) and affusions of warm 
water, whose temperature varied from 30 to 35 ° C. (86° to 95 ° F). He believes these latter 
affusions to produce as satisfactory a lowering of the temperature of the body as cold 
affusions; he joined to them also the internal usage of cold drinks. 

When one reads attentively the work of Currie it is plainly evident that he employed 
cold or tepid lotions not so much to abstract heat as to tonify the organism, and it was 
rather the reaction which he sought than the thermic depression. 

The doctrine of Currie fell into oblivion. Forty-nine years elapsed before attention 
was again called to this practice, and this time in France. Jacques, of Lure, revived Currie's 
method in 1846; a method which he had adopted since 1839 xn t ^ ie treatment of typhoid fever, 
and which consisted in applying over the forehead and abdomen and different parts of the 
body compresses of cold water ; these he ordered to be renewed every ten minutes; he also 
administered cold lavements and cold drinks. Out of 143 patients affected with typhoid 
fever and treated after this manner he had but nine fatal cases, while out of 349 typhoid 
patients treated by the other methods he had had 91 deaths. 

In 1849, Wanner set forth a treatment of typhoid fever which consisted in giving cold 
water for the only drink, and applying lotions over the whole body of ice-cold water; and 
from this time onward, in successive memoirs Wanner affirms that with his method 
persistently carried out of lotions and ice water, which he calls "passes," he has the 
experimental certainty of triumphing over every case of typhoid fever whose date of 
invasion does not exceed one week. 

In 1852 Leroy, of Bethune, maintained that by cold water internally and externally 
one could almost certainly cure typhoid fever. 

In 1851, Brand, a physician in Stetin, published his first treatise on the employ of 
cold water in the treatment of typhoid fever. His first affirmations are a little hesitating, 
and he expresses himself thus: "If typhoid fever is treated from the commencement by 
cold water, there is in general nothing to fear, and even in cases the most grave one may 
yet many times obtain cure by cold water." In 1863 Brand becomes still more positive, 
and he now says: "Every case of typhoid fever treated regularly, according to my method, 
takes on a light character and almost never terminates by death, so that in fact we may say 
that Clinical Medicine is in condition to preserve with certainty the lives of all patients 
entrusted to its care." In 1868 he assures us an absolute cure by his method, in the following 
terms: "The treatment by cold baths, methodically employed from the commencement, 
gives a success positively ensured, and always enables one to ward off death." Glenard, of 



358 



FEVER FROM A THERAPEUTIC STAND-POINT. 



and shall limit myself in this place to a consideration of the method of 
Brand, from the stand-point of the physiological pathology of the febrile 
process. 

The refrigerant method comprehends several modes of application. You 
may use baths, lotions, compresses wet in cold water, bladders of ice, or you 
may use the ingenious apparatus of Dumontpallier, or even rectal injections of 
cold water. 2 In all these forms the water may have a variable temperature 
which is always less than that of the fever patient. But whether you resort to 
cold affusions, ice bags, or cold lavements, these frigorific means abstract heat 

Lyons has deduced from the sum total of Brand's works, this aphorism: "Every case of 
typhoid fever, treated regularly from the commencement by cold water will be exempt from 
complications, and will get well." 

Huchard, basing himself on the works of French physicians, anterior to those of 
Brand, maintains that we ought to substitute the term French method, for that of German 
method (method of Brand) when we speak of the application of refrigeration to typhoid 
fever, {a) 

2 Riegel in studying the action of cold applications on the temperature of fever 
patients has observed that on applying to the thorax compresses dipped in ice water, the 
axillary temperature at the end of an hour falls from o°.2 to o°.27, and the rectal tempera- 
ture from o°.i to o°,05. At the same time, Liebermeister observes that in the local applica- 
tions it is necessary that the refrigeration should be very pronounced, and its application 
very prolonged. 

Riegel has also made some quite interesting experiments in comparing in a typhoid 
fever patient the effect of baths at i8° C. and renewed every two hours, whenever the axillary 
temperature exceeded 39. 5 C, with the effect obtained by two bladders of ice applied per- 
manently to the thorax. The following are the results which he obtained: 

BATHS AT l8°.75 C. EVERY TWO HOURS WHENEVER THE AXILLARY 
TEMPERATURE EXCEEDS 39.5° C. 



1st Exoeriment. 

2d 

3d 

4th 

5 th 

6th 

7 th 

9th 



Average 


of 


Average of 


Rectal 




Axillary 


Temperature. 


Temperature. 


39-69 




39.18 


39-71 




39 


69 


39-93 




39 


55 


40.01 




40 


03 


39-65 




39 


5i 


39-o8 




39 


84 


40.21 




40 


09 


39.28 




39 


34 



{a) James Currie, Medical Reports of the effects of water, cold and warm, as a remedy in fever and 
other diseases, whether applied to the surface of the body or used internally, including an inquiry into the 
circumstances that render cold drinks, or the cold baths, dangerous in health; to which are added observations 
on the nature of fever, and on the effects of opium, alcohol, and inanition, 5th edit., 2 vol., London, 1814. — 
Jacquez (de Lure), Bull, de la Soc. m£d. de Besancon, No. 2. — Wanner, De l'emploi de la glace comme 
agent therapeutique et deslois a observer dans son mode d'administration soit dans les cas de medecine, soit 
dans les cas de chirurgie (Compt. rend, de l'Acad. des sc, t. XXIX, p. 581, 1849. De la guerison constante, 
quinze jours au plus tard apres 1'application du traitment etcela sans nulle convalescence, de toute fievre 
typholde dont la periode d'invasion ne depasse pas sept jours (Acad, de med., 1866). 



FEVER FROM A THERAPEUTIC STAND-POINT. 



359 



and lower the thermometric curve, on condition, always, that there exist be- 
tween the temperature of the patient and that of the bath a notable difference. 
Liebermeister, in his remarkable researches on calorimetry, has shown 
us that in a well man the production of heat is in direct relation with the 
loss of heat. If we apply these data to the refrigerant methods, the result 
will be that thermogenesis, instead of being diminished, will be increased pro- 
portionately to the withdrawal of heat; and reasoning a priori, it is not easy to 
see what good you are accomplishing by this means. Liebermeister, I am 
well aware, while recognizing that the regulation of heat is the same in the 
well person as in the febrile individual, has endeavored to prove that in pyrexia 
cold baths produce much more rapidly a diminution in thermogenesis than in 
the normal state; but it is none the less certain from the stand point of the 
physical laws of calorimetry, that as fast as you abstract heat from the fever 
patient, the same amount of heat is produced anew. So true is this, that to ob- 
tain an enduring effect, one is obliged in practice to renew continually the 
refrigerant applications. Whether the fever patient raise the temperature of 
the bath, or his own temperature, the effect is the same, and the lesions which 
you seek to avoid by this means, and which result, not from the elevation of 
temperature merely, but from the exaggeration of the calorific functions of the 
economy, will be produced in both cases, and from the strict point of observa- 
tion of physical laws we should say that the refrigerant method can confer no 

TWO BLADDERS OF ICE APPLIED OVER THE THROAX AND ABDOMEN 
DURING THE ENTIRE DURATION OF THE EXPERIMENT. 



ist Experiment 

2d 

3d 

4th 

5 th 

6th 

7 th 

9th 



Average of 

Rectal 

Temperature, 



Average of 

Axillary 

Temperature. 



37-34 
37-81 
37-97 
39-27 
39-27 
37-75 
40.05 
38.40 



A lavement of one litre of water at 



Diminishes the heat of the body 



Foltz, of Lyons, has studied the influence of cold lavements on the heat-fall. 
According to him, a lavement of one litre of water produces the following thermic de- 
pressions: 

+ 5° 
+ 10 

+ 14 

+ 20 
+ 32 



o . 52 

o .52 

o -35 

o .29 

o .14 

o .06 (a) 



(a) Riegel, Ueber Warrneregulation und hydrotherapie (Deutsch . Arch, of Klin. Med., t. IX, p. 591, 
1872.) Foltz, Du lavement froid (Lyon Medical, Janvier 1875). 



360 FEVER FROM A THERAPEUTIC STAND-POINT. 

therapeutic benefit whatever; nevertheless, a real benefit is derived, and you 
will see when we come to study the therapeutic applications of cold baths, that 
they produce a marked relief in many cases. 

How are we to explain this difference between the result in theory and the 
result in practice? Simply in this way; the refrigerant applications in fever do 
not act merely mechanically in removing heat, but they modify profoundly, and 
often durably, the functions of the nervous system, and particularly of the vaso- 
motors, all of which, as you know, play so considerable a part in the pro- 
duction of the febrile process, and in this respect Currie seems to me to have 
rendered a better judgment concerning the action of the refrigerant medication 
in fever, than even Brand and his pupils. 

The action of blood-letting as an antipyretic agent seems to me to belong 
to that of refrigerants generally, and this, because in withdrawing at a given 
moment a certain quantity of blood you withdraw also a certain quantity of 
caloric. Moreover, this antipyretic action produced by sanguineous losses, is 
one of the most real known, and it suffices to examine what takes place in 
patients who have had during the course of typhoid fever an intestinal hemor- 
rhage of moderate intensity, to observe the manifest and durable effect of 
hemorrhages on thermogenesis. 

The influence of hemorrhage on pyrexia is complex. The loss of blood has 
abstracted heat, it is true, but it has also modified the physico-chemical processes 
which take place in the interior of the tissues, and the functions of the nervous 
system have also been affected by it. These multiple affections manifest them- 
selves on the elevation of the temperature in pyrexia by effects more enduring 
than those of cold baths, and we always observe this immediate fall in the febrile " 
heat unless the patient dies in the hemorrhage. 

Quite different is the action of the medicaments which constitute the 
second group of anti-febrile remedies, and their influence is explicable either 
by a direct action on the nervous system or by morbid changes effected in 
the blood. 

Digitalis is a fair type of anti-febrile agents acting on the nervous system. 
I have before told you how digitalis acts in diseases of the heart, and the prin- 
ciples there established apply to its antipyretic influence. Hirtz is one of the 
most earnest partisans of the treatment of fevers by digitalis, and his followers 
have shown us the benefits which we may derive from this medicine in the 
divers febrile processes. You obtain from digitalis not only a lowering of the 
pulse, but also a very evident thermic depression. Nevertheless the precepts 
of the ancient school of Strasbourg have not been admitted by all, and it is only 
exceptionally that we see digitalis prescribed in fever; and this results from the 
fact that this remedy has a powerful emeto-cathartic action on the one hand, 
and on the other, it is not quite safe to prolong to any extent the action of such 
a drug in septic and infectious diseases where the heart is prone to undergo 
fatty degeneration. 

It is this same action on the spinal cord and medulla oblongata which ex- 
plains the anti-febrile effects of colchicine, aconitine, etc., but as in the case of 
digitalis this influence on thermogenesis is not obtained without serious incon- 



FEVER FROM A THERAPEUTIC STAND-POINT. 361 

veniences, by reason of the large doses which it is necessary to give and which 
are not without danger in the case of alkaloids as powerful as those which I 
have mentioned. 

Quinine, whose physiological action I propose to explain more completely 
when I come to speak of the treatment of intermittent fever — quinine, which is 
one of the most powerful agents of the antipyretic medication, acts, as you 
know, not only on the nervous system, but also on the blood; in both modes 
influencing thermogenesis. This class of medicaments has lately assumed a 
preponderant importance, since the labors of Pasteur have shown us the im- 
portant part which the proto-organisms have in the production of infectious and 
virulent diseases. Chemistry furnishes us under the name of the aromatic series^ 
a group of bodies, phenols, or oxy-phenols, which all possess the property of 
arresting more or less completely the development of micro-organisms. These 
bodies, such as phenic acid, salicylic acid, kairine, resorcine, etc., were all first 
employed in the treatment of wounds, as a result of the radical change which 
Lister had just introduced into the dressing and manipulations of operative 
surgery; then the idea occurred to give these same bactericide medicines inter- 
nally when there seems to be an indication to destroy the septic agents of dis- 
ease, these being supposed to be bacilli 

But the results were really unexpected, for if there were no direct proofs of 
the destruction of the micrococcus in the interior of the organism, a most 
marked antipyretic effect was obtained, and these bodies of the phenol series, 
became the most energetic agents of the anti-febrile medication. 

It is, in fact, by employing the derivatives of this series, carbolic acid, sali- 
cylic acid, resorcin, kairine,* and especially with this latter, that we obtain the 

* [Karine, thalline and antipyrine are three new antipyretics for which we are indebted 
to the industry of continental chemists in the application of the synthetical methods to the 
formation of new compounds. As for Karine, readers of the Therapeutic Gazette will find 
this antipyretic discussed in the volume for 1884, in the following pages: 46, 105, 95, 129, 
142, 153, 164, 254, 313, 285, 335, 378. From Dr. Tangeman's article (Ther. Gaz. 1884, p. 
105) we extract the following particulars: 

Karine was discovered in 1883 by Fisher, of Munich; (its chemical formula is 
C 10 H 13 NO). Fisher has experimented quite largely on animals with this drug, but Filhene 
has employed it very extensively on the human subject both in health and disease. Since 
then the subject has been thorougly studied by Seifert, Drasche and others. If it can be 
shown that this new antipyretic is equally as good as quinine much has been gained. That 
it is an efficient drug under certain circumstances nobody will doubt who has ever observed 
its effects. Two preparations are at present in the market: the sulphate and hydrochlorate 
of karine; the former is a crystalline substauce of a yellowish-white color, its taste is very 
unpleasant, and is not much of an improvement on some of the older remedies. 

The study of the physiological action of this drug on animals has not produced very 
satisfactory results. On man in health it does not have any tendency to depress the tem- 
perature below normal; the hearts action is somewhat slowed, as is also the respiratory act. 
In disease its action is more marked. There is no condition in which karine does not mani- 
fest its antithermic action if given in sufficiently large doses. This does not say that it is 
indicated in all febrile conditions, or that its administration can safely be recommended in 
all cases. 

There seems to be a great variance of opinion as to the proper dose of this drug by the 
different experimenters, but this may be only apparent. I think we can explain this differ- 



362 FEVER FROM A THERAPEUTIC STAND-POINT. 

most considerable depressions of temperature; you will often see the mercury 
fall two, three, and even live degrees in the course of a febrile state, and I pro- 
pose in the next lecture to state more particularly the therapeutic effects of each 
of these substances. But I must tell you once for all that such depressions of 
temperature are not without danger, and that at the same time that we observe 
this thermal fall we observe also a general depression of the organism and mul- 
tiple congestions in the different viscera. 

Is it solely by their action on the blood that the medicaments of the aro- 
matic series produce such powerful effects on thermogenesis? Is it only by 
opposing the progress and development of fermentations, the original cause of 
the febrile processes, that their antipyretic action is exercised? It is difficult 



ence by carefully studying the physiological action of the drug. While its tendency is to 
reduce the temperature, in every febrile condition the state of the patient physically as well 
pathologically must be taken in consideration. Its main field of efficiency will undoubtedly 
be found in diseases where neither the heart nor the lungs are primarily affected; but where 
the fever is a long-continued pyrexia we ma)' - expect more, since its action does not 
in the least influence or abort the natural course of the disease. The safest method to 
administer this drug is to begin with a small dose and watch the effect with the thermometer 
until we have arrived at the correct and safe dose for that individual case — a dose that will 
keep the temperature at a point almost normal. In this manner we are able to better guard 
against collapse, and at the same time avoid the objectionable symptom of chilliness that is 
experienced by patients when the temperature rises again after a large dose of karine. Un- 
pleasant after-effects are met with occasionally, but they are not dangerous to the patient; 
the remedy is one of the safest powerful antipyretics in our possession, if carefully 
watched. The adult dose generally varies from 0.3 to 1 and 2 grm. repeated every hour- 
The effect of a large dose is very rapid sometimes, 20 to 25 minutes being sufficient to cause 
a decline in temperature; but the effect passes off just as quickly. Therefore, the frequent 
repetition of the dose becomes necessary. It may range from 12 to 15 grm. per day given 
in 18 to 20 doses. 

The drug is best administered in capsules on account of its bitter taste. My experience 
with karine has been limited, and in some respects differs from the results of other observers. 
Altogether I have used it in five cases. 

" In many instances the patients absolutely refuse to take the medicine any longer, on 
account of the bad taste and nausea that it produces. The drug seems to be largely elimin- 
ated by the kidneys; it can be found in the urine 30 to 35 minutes after administration. 
Whenever there is a marked decline of temperature there is profuse perspiration. The drug 
may become quite valuable in diseases of the kidney, or in cases where a reduction of 
temperature and an elimination of poisonous material from the blood is desirable. 

In rheumatism it has been given with excellent results. The action of karine subsides 
very rapidly, therefore frequent doses are necessary to maintain a permanent effect; the 
thermometer is our guide, which must be used frequently; upon the slightest chilliness a half 
dose should be administered. Absolute laws governing the dose and action of karine in all 
cases cannot be laid down. In feeble and decrepid individuals it must be given with con- 
siderable care, since it may, when given in large doses, suddenly produce collapse." 

In the Therapeutic Gazette for February, 1885, is an able aditorial on the subject, from 
which we cite the concluding portion: 

" Guttmann has given karine in cases of pneumonia, measles, phthisis, typhoid fever, 
scarlatina, pleurisy, peritonitis, erysipelas, ague, septicaemia, and apparently always with 
advantage. On the other hand, Dr. H. Menche's (of Rheydt) experience with it in the 
pyrexia! stages of pneumonia, pleurisy, and pernicious anaemia was unfavorable, which has 
been attributed by others to the use of large doses. In rheumatism, he found that its use 



FEVER FROM A THERAPEUTIC STAND-POINT. 363 

to respond categorically to these questions, and without denying the action of 
these substances on the intimate processes which take place in the blood, I ven- 
ture to affirm that we must attribute a part of their effect in lowering pyrexial 
heat, to their action on the nervous system, and particularly the vaso-motors. 

In a recent communication to the academy of sciences, Prof. Gosselin has 
well set forth this action of phenic acid on the capillary net work, and he has 
shown us that when you apply locally to wounds lotions of carbolic acid, the 
antiseptic actions of these dressings result much more from the obliteration of 

was followed by diminution of the pain, but not by any reduction in the swelling of the 
joints." 

"The cases just reported demonstrate that karine possesses the power of reducing the 
temperature of the body in fever to an unusual degree, and that it does this with certainty 
and promptitude, and, it may be added, when moderate doses are used, with safety. One 
care, however, it is necessary to exercise in its administration, and that is to use fresh speci- 
mens of the drug only, as it undergoes change if kept for any length of time. It reduces the 
temperature much more rapidly than quinine, although the apyrexia produced by it is of 
much shorter duration than that caused by the latter. It is also capable of depressing the 
temperature during the evening exacerbations of fever, while the most marked results are 
obtained, on the other hand, from quinine just before the morning's remission. Its use is 
also free from some of the objections usually urged against the latter, as it does not give rise 
to unpleasant effects, such as headache, ringing in the ears, and the like. Although less 
rapid in its action than the cold bath, it is obvious that it may be administered in many cases 
in which resort to the latter would be impossible. The excitement and terror which are 
often occasioned by the use of the bath, even when it is brought to the bedside of the 
patient, constitute a positive objection to it, which, in the author's opinion, becomes insuper- 
able in cases in which it is necessary to carry him some distance to a bath room. It is said 
to exert a marked and favorable influence over the brain-symptoms which occur in fevers, 
possessing, in this respect, an undeniable advantage over several of the other antipyretics." 

Thallin has lately been successfully used in a large number of cases in the clinic of 
Professor Nothnagel. It has the constitution of a secondary quinoline base, being one of 
a number of quinoline derivatives prepared by Prof. Skraup, and is represented by the 
systemic name tetrahydroparachinanisol. The salts of this base, which have an acid reaction, 
are freely soluble in water and have the property of forming green compounds when treated 
with solution of ferric, chloride, and oxidizing agents. On account of this peculiarity, the 
cumbrous systemic name has been dropped, in favor of the shorter designation, " thallin." 
The hydrochlorate tartrate and sulphate of thallin, and the hydrochlorate of ethyl thallin are 
the salts which have been employed, and these are said to show great antipyretic activity in 
doses of half and three-quarters of a gramme, a point in which thallin would seem to com- 
pare favorably with its competitors. It can be given in wafers, each containing a quarter or 
half a gramme. It causes a speedy and marked fall in the temperature which lasts several 
hours. (London Lancet, Dec. 6th, 1884, p. 1018.) 

" In the fourth edition of my work " writes Dr. Dujardin-Beaumetz to me, under date, 
June 10th, 1885, " I have given special attention to antipyrine, karine and thallin. We now 
divide antithermics into three groups; those which mechanically abstract heat, and of which 
the cold bath is the type; those which act in the thermogenetic centres, of which the types are 
quinine, resorcin, salicylic acid, antipyrine, lastly those which act in destroying the respira- 
tory power of the blood, of which karine and thallin are the tj^pes. There exists an 
intermediate class, constituted by phenic acid, which acts at once on the thermogenetic 
nervous centres and on the respiratory power of the blood." 

I have appended to the lecture on Typhoid Fever a note pertaining to antipyrine in 
which the latest researches on this new medicament are detailed. This is the only one of 
the series of new antipyretics which is likely to come into favor. — Translator.] 



364 FEVER FROM A THERAPEUTIC STAND-POINT. 

of all the capillary openings in the wound, than from the special destructive in- 
fluence of carbolic acid on the virulent principles. Laborde has completed 
these researches in showing us that this capillary obliteration is due to an action 
of carbolic acid on the vaso-constrictors. 

It is probable that like effects are produced in fever, and that phenic acid 
once introduced into the blood acts on the vaso-motor centres either directly or 
indirectly, and thus modifies the conditions of febrile thermogenesis. As you 
see, gentlemen, therapeutics confirms in a certain measure, the data furnished 
us by physiological pathology, and shows us the unbounded and preponderant 
influence of the nervous system on the febrile processes. 

In the next lectures we shall make numerous and practical applications of 
the deductions which flow from this general survey, and you will see the im- 
portance of all these developments into which I have entered. 



ON THE TREATMENT OF TYPHOID FEVER. 

Summary. — Typhoid Fever — Etiology — Spontaneity — Contagiousness — Theory of Typhoid 
Contagion — The Microbe of Typhoid Fever — The Virus of Typhoid Fever — Theories of 
the Contagion — Fecal Matters — Fecal Theories — Sewerage — Aliments — Overcrowding — 
Experimental Physiology of Typhoid Fever — Public Hygiene — Private Hygiene — 
Hygienic Treatment of Typhoid Fever — Alimentation — Oration — Cleanliness — Treat- 
ments of Typhoid Fever — Divisions — Antithermic Medication — Method of Refrigera- 
tion — Cold Baths — Brand's Method — Its Application — Its Results — Its Advantages — Its 
Disadvantages — Warm Baths — Refrigerant Apparatus — Cold Lotions — Cold Lavements 
— Antiphlogistic Method — Local Bloodletting — General Bloodletting — Antipyretic 
Medication — Digitalis — Quinine — Antiparasitic Method — The Aromatic Series — Phenic 
Acid — Salicylic Acid — Resorcin — Kairine — Evacuant Medication — Purgatives 
— Calomel — Mercurials — Tonic Medication — Alcohols — Cinchona — Exclusive 
Medications — Their Dangers — Expectancy — Treatment of Indications — Armed 
Expectancy — Bases of this Medication — State of the Forces — Intensity of the 
Fever — Treatment of the Complications — Nervous Complications — Pulmonary Com- 
plications — Abdominal Complications — Conclusions. 

Gentlemen — There is, perhaps, no question in therapeutics which has 
caused so much discussion as the treatment of typhoid fever, and, if I were to 
follow out all the lines of inquiry which this subject has opened, I should re- 
quire, not one lecture, but the entire course. I shall, then, be as brief as pos- 
sible on points of theory, and dwell rather on practical conclusions. Whether 
you practise in the country or in the city, you will continually meet with cases 
of abdominal typhus. Last year (1882) you saw our wards filled with the vic- 
tims of one of the most severe epidemics that have ever afflicted the population 
of Paris, and the hall of the Academy of Medicine stills rings with the passion- 
ate discussions which were raised by the various questions pertaining to this 
great problem of hygiene and therapeutics. 1 

Etiology, as I have often told you, has an important bearing on the treat- 
ment of disease; you recognize, then, the propriety of considering first the 
causes of typhoid fever; for, if they were absolutely known to us, we should be 
able henceforth to establish on a scientific basis the prophylactic treatment of 
this disease. This particular point in the study of dothinenteritis has been 
especially investigated during the last few years, and we shall have here to dis- 

1 Read the discussion which was held in 1882 and 1883 at the Academy of Medicine on 
typhoid fever ; a discussion in which the following gentlemen took part : Marjolin, Proust, 
Fauvel, Rochard, Lagneau, Leon Colin, Bouchardat, Gueneau de Mussy, on the part of 
hygiene ; Herard, Germain See, Dujardin Beaumetz, Peter, Jaccoud, Vulpian, Bouley, 
Glenard, on the part of therapeutics. (Bull, de l'Acad. de Med., 1883.) Read also the discus- 
sion which took place at the same Academy in 1876 and 1877, and in which H. Gueneau de 
Mussy, Bouillaud, Brouley, Bouchardat, Jaccoud, Jules Guerin, Chauffard took part. (Bull. 
de l'Acad. de Med., 1876, 1877.) Read finally the discussion which was held at the Academy 
of Medicine apropos of the epidemic which broke out in Brussels in 1869, and where Martin, 
Coussot, Crocq, and Boens had the floor. (Bull, de l'Acad. de Med. de Belgique, 1875, 1876.) 

365 



366 ON THE TREATMENT OF TYPHOID FEVER. 

cuss the contagiousness and spontaneity of this affection. According to some 
authorities, typhoid fever is always the result of a particular contagion ; accord- 
ing to others, it comes from a miasmatic poison. You cannot be ignorant, 
gentlemen, of the difference which separates contagium from miasm, a. distinc- 
tion well established by Liebermeister ; contagium, coming from specific, mor- 
bific agents, which always take their origin and undergo development in a dis- 
eased organism ; miasm, on the contrary, being generated outside of, and inde- 
pendent of, an infected organism. To make more orderly and clear the exposi- 
tion of this difficult subject, I shall commence with points which are best estab- 
lished and least open to dispute ; then I shall take up those which are most 
amenable to discussion. 

To-day, everybody is agreed in admitting the contagiousness of typhoid 
fever. It is especially in our rural districts that this contagion is observed in its 
worst form, and every year the reports made to the Academy of Medicine on the 
prevalent epidemics contain facts establishing the contagiousness of this disease. 
We can go even further, and declare that to-day the active principle of this con- 
tagium has been determined. The principle is found exclusively in the stools of 
typhoid patients, and it needs but a very minute quantity of this pernicious 
element in potable water to communicate ileo-typhus to all who drink it. We 
possess, to-day, a considerable number of observations which establish this fact 
on an undisputable basis. The latest and most accurate is, assuredly, the 
observation published by Dionis des Carrieres, concerning the epidemic which 
lately devastated the city of Auxerre, where one of the springs which supply the 
city was proved to have been polluted by the dejections of a woman sick with 
typhoid fever. 1 The entire population which derived its drinking water from 
this source was infected, and there were few that did not suffer more or less; 
those parts of the city, however, which did not make use of this water, had 
entire immunity from the epidemic. 

The attempt has been made by experiments on animals to elucidate this 
subject, but these have given uncertain results, and to the positive experiments 
of Birch-Hirschfeld, of Letzerich, and of Tizzoni, we must oppose the negative 
results of Robert Bahrd and Motschutkoffsky; moreover, the basic premise of 
these researches is under dispute, for it is not proved that the lower animals 
can contract typhoid fever. 2 



1 Dionis des Carrieres, on an epidemic of typhoid fever which ravaged the city of 
Auxerre in 1882. (Bui. et Mem. de la Soc. des hop., 1883, et Un. med., 1883). [A similar 
epidemic prevailed this year (1885) in Plymouth, Pennsylvania, among those portions of 
the population that used water from a reservoir that was polluted by the dejections of a 
typhoid patient ; these fecal excreta having been consigned to the stream that fed the re- 
servoir. — Tr.]. 

2 In experiments made on animals, the hare is generally selected in preference to other 
animals, this animal being subject, according to Kuchenmeister, to an affection very similar 
to ileo-typhus; an affection characterized by augmentation (yet without ulceration) of Peyer's 
patches. 

Birch-Hirschfeld, of Dresden, has experimented on animals with typhoid dejections, 
giving these to hares to eat. They succumbed at the end of from three to thirty days, and 



ON THE TREATMENT OF TYPHOID FEVER. 36*7 

But it is not enough to know that it is by the dejections that typhoid fever 
is communicated. Pathologists, guided by the theories of Pasteur, have sought 
in the dejections, and even in the tissues of victims of the disease, the microbe 
which contains the contagious principle. Unfortunately, we have not here any 
positive information; not because micro-organisms are not exceedingly abund- 
ant in the stools of typhoid patients, but because amid this abundance it is 
difficult to tell exactly which one of these microbes is the essential element of 
dothinenteritis. 3 It is generally known that Recklinghausen has found micro- 
cocci, Eberth, rod-like forms, and Klebs has described, under the name of 
bacillus typhosus, certain elongated filaments; but despite these researches, and 
those of Koch, of Meyer, of Friedlander, of Maragliano, of Almquist, we are 

presented, at the autopsy, the characteristic lesions of Peyer's patches. Ordinary diarrhceal 
matters, administered to hares, did not produce any of these symptoms. 

Jules Guerin in also experimenting on the same animals, and in injecting, under their 
skin, from one to two drachms of fecal matters, of urine, or of the blood of typhoid patients, 
has caused the death of the hares with symptoms similar to those of abdominal typhus. 

Letzerich injected, in the subcutaneous cellular tissue of hares, distilled water, holding 
in suspension certain inferior organisms obtained by subjecting to repeated washings the 
stools of individuals dead from typhoid fever, and always determined a disease identical with 
typhoid fever. This affection commences always by the intestine, and induces ulceration 
of Peyer's patches. The same organisms develop also in the spleen, kidneys, and mesen- 
teric glands. 

Tizzoni, in an epidemic at Catana, injected in animals the organic insoluble matters 
extracted from drinking-water by filtration, and determined in them symptoms analogous 
to typhoid fever. The anatomical lesions of this experimental typhus are the result of the 
presence of numerous micrococci in the parenchyma of the spleen, and mesenteric glands. 

But by the side of these favorable results we must note the contradictory experiments 
of Robert Bahrd, and of Motschutkoffsky. 

Robert Bahrd, after injecting into the abdomen of hares from \ gramme to 50 grammes 
of the fecal matters of typhoid patients, and causing them to live on a soil impregnated 
with these matters, obtained no results. 

Motschutkoffsky, of Odessa, has made experiments with the blood and excrementitious 
matters of patients affected with typhoid fever, of syphilis, of rheumatism, and of recurrent 
fever, employing as his subjects, monkeys, goats, and even men. The results were nega- 
tive as far as the first two diseases were concerned, positive only in the case of recurrent 
fever, (a) 

3 Recklinghausen was the first to find micrococci in the intestinal ulcers of typhoid 
patients. 

Klein discovered the same micro-organisms in the intestinal mucosa, Sokoloff in the 
spleen, and Fischel in the lymphatic glands. In 1877 Feltz found figured ferments suscept- 
ible of culture in the blood of typhoid patients. 

Eberth, in 1880, endeavored to isolate the micro-organisms of typhoid fever, but he 
found that this separation is very difficult. The same year, Klebs and his pupil, Epinger, 



(a) Birch-Hirschfeld, Untersuchungen zur pathologie des Abdominaltyphus (Klin. Wochens., No. 52, 29 
decembre). — Jules Guerin, Experiences sur l'origine et la nature de la fievre typhoide (Compt. rend. acad. des 
sc, 26 fe>rier 1877).— Letzerich, Experimentelle Untersuchungen liber typhus abdominalis (Arch. f. experi- 
ment. Path, und Pharm., Bd. XX, heft 3 et 4, p. 312, 1878). — Tizzoni, Studii di Pathologia Sperimentale sulla 
genesi e sulla natura del tifo abdominale (Ann. univ. di Med. e Chir., fevrier 1880). — Robert Bahrd, Experi- 
mentelle Untersuchungen iiber die Uebertragbarkeit der Typhus abdominalis auf thiere (Arch, der Heilk., 
XVII, p. 156). — Motschutkoffsky, Experimentale studien iiber die im barkeit typhceses fieber (Centr. f. d. Med. 
Woss., 1876, No. 11).— Homolle, Revue g^nerale sur la fievre typo'ide (Rev. des sc. m.66.., t. X, p. 681). 



368 ON THE TREATMENT OF TYPHOID FEVER. 

still ignorant of the real microbe of typhus abdominalis. In a word, the para- 
sitic theory of typhoid fever is almost certain, but it has not yet been scientific- 
ally demonstrated in a rigorous manner. 

As opposed to this doctrine of contagiousness, we must allude to that of 
spontaneity. Struck by the fact that typhoid fever exists endemically in all 
places where are accumulated a great number of individuals — as in our great 
city; moved also by the appearance of certain epidemics apart from all known 
contagion; comparing, moreover, the typhus of armies with the abdominal 
typhus of great cities, certain authorities have maintained that typhoid fever 
may be produced spontaneously under the influence of bad hygienic conditions; 
and the cause has been by turns assigned to fecal matters, overcrowding, spoiled 
alimentary substances, and even to certain bad geological conditions of the soil. 
Let us rapidly examine each of these points. 

Murchison has been the chief defender of the first of these causes, and he 
has labored to show that fecal matters may spontaneously develop a miasmatic 
principle which, entering the human system, may engender there ileo-typhus. 
Between him and Budd quite a lively discussion arose; Budd maintaining that 
fecal matters were dangerous only when they were fouled by the dejections of 
a typhoid patient. 4 

These are the two so-called fecal theories of typhoid fever. It was, how- 
ever, a mistake to confound these theories under one name, for if Budd's view 

claimed that they had discovered the parasite of typhoid fever. The bacillus typhosus, 
according to them, when it is completely developed, is constituted by certain entire filaments 
Oju 50 in length, by Oju 2 in breadth. Experiments made on hares have demonstrated that 
the inoculation of these microbes determines symptoms similar to those of typhoid fever. - 
Nevertheless, the attentive study of these observations does not prove that the animals really 
had typhoid fever. 

Brautlecht has also found a microbe in typhoid fever, but which is quite different from 
the one described by Klebs. 

According to Koch, micro-organisms of three different species have been found: micro- 
cocci, large and short rods (Eberth), and elongated filaments (Klebs). It is difficult, accord- 
ing to him, to determine the veritable infectious agents in typhoid fever. At the same time, 
the presence of these groups of rods in the internal organs has a real importance. W. 
Meyer, Friedlaender, Maraglano, Almquist, have also noticed the presence of the bacillus 
typhosus, (a) 

4 Budd has affirmed the following propositions: 

1. Typhoid fever is a disease essentially contagious. 

2. The irritant substance which produces the contagion comes almost exclusively 
from the intestine of the typhoid patient. 

3. The cess-pools and the sewer-pipes, which are the direct continuation of the dis- 



(«) Recklinghausen, Ueber den Abdominaltyphus (Wurtzburger Zeitung, 10 juin 1871).— Eberth, Die 
organismen in den Organen der Typhus abdominalis (Arch. f. Path. Anat. und Phys., LXXXI, p. 58). Neue 
Untersuchungen iiber den Bacillus des Abdomioaltyphus (ibid., LXXXIII, p. 486)— Klein, On the enteric 
fever (Reports of the med. office of the Privy Coun. and local Government Board, 1875).— Sokoloff, Zur 
Pathologic der Acuten Miitztumors (Arch, fur Path. Anat. und Phys., t. LXVI, 1876, p. 171). — Klebs, Der 
Typhus abdominales eine Schistomikose (Arch. f. sper. Path., 1880). Der Bacillus der Abdominaltyphus und 
der typhose Procets (ibid., XII, 1881, p. 381 et 399). — Koch, Mittheilungen ausdem k. Gesundheistamte, p. 45. 
— V. Meyer, Untersuchungen iiber den Bacillus des Abdominaltyphus (these de Berlin, 1881). — Friedlaender, 
Notiz ueber typhus bacillen (Dubois Reymond's Arch., 1881). — E. Maragliano, Pathogenese des Abdominal- 
typhus (Cent fiir Med. Wiss., 1882, No. 11).— Almquist, Typhoids feberus. Bacterie, Stockholm, 1883. 



ON THE TREATMENT OF TYPHOID FEVER. 369 

be correct, Murchison's cannot be; for it is not yet rigorously demonstrated 
that fecal matters may spontaneously generate the typhoid poison. This fecal 
theory has served as an argument to the adversaries and to the partisans of the 
exclusive sewerage doctrine, 5 which condemns the fixed privy-vaults and the 
separate systems of removal, and insists that all night-soil shall be consigned to 
the public sewers, which shall be constantly flushed with running water — the 
latter, with its excrementitious products, being finally subjected to the filtering 
and purifying action of the soil. This whole matter of sewerage is not yet 
settled; yet despite the opposition in certain quarters, the majority of hygienists 
and civil engineers are of opinion that those cities which have the best system 
of sewerage are the best protected from typhoid epidemics. 

I do not wish to enter into the details of fhis discussion, which would draw 

eased intestine, are the constant source of the propagation of typhoid fever, by diffusing their 
noxious principles into the atmosphere, and the potable water sources. 

4. But the contents of sewers, and the putrefactions there taking place, do not produce 
typhoid fever until there is mixed with them, at some period or other, real typhoid stools. 

Murchison has, on the other hand, pretended that typhoid fever, an endemic disease, 
may arise independently of any previous case or contagion, from the fermentation of fecal 
matters, and perhaps from the fermentation of other forms of organic matters. 

Biermer has studied the typhic poison. This poison, according to him, is of animal 
nature; it may be transported by the patient and by his clothing. The poison exists only in 
the dejections, and it is these latter which render the disease contagious whenever they are 
placed in favorable conditions. The air does not seem to waft the contagion, but it is surely 
and rapidly transported by the water of springs and streams. 

Cousot has given especial attention to the typhogenous miasm. According to him, the 
contagia are living, and the theory of animated virus explains the anatomical and functional 
lesions of dothinenteritis. In his opinion, the virus does not develop in the blood, but in 
the lymphatic system, and especially in the ganglia, which are the principal, if not the only 
seat of the evolution of the contagion. 

Bouchard rejects both the doctrine of contagion and infection; he considers the theory 
of fecal origin and that of spontaneous development as not proven. According to him, 
typhoid fever is a specific and miasmatic disease, (a) 

5 As for this question of sewers and cess-pools, it is worth the while to refer to the 
discussion which was held at the meetings of the Society of Public Hygiene, during the year 
1883, and in particular to the discourses of Durand-Claye and Emile Trelat, advocates of the 
" all for sewers" system, and of Brouardel, Vidal, Duverdy, opponents of this system. 

One may also appropriately consult the proceedings of the International Congress of 
Hygiene, which was held at Geneva in 1883, where this question was discussed in the ses- 
sions of the 5th, 6th, and 7th of September. 

Warrant of Frankfort-on-the-Main, reporter, Smith of London, Hauser of Leipsig, 
Soyka of Munich, Bourrit of Geneva, have defended the advantages of the " all for 
sewerage" method. Van Overbeck de Meyer of Utrech, and Williem of Mons, have 
declared themselves partisans of the system of Liernur, which is characterized by the 
delivery of fecal matters in a system of closed pipes separate from the sewers. 

The Technical Commission for promotion of the salubrity of Paris, adopted conclusions 



(a) Biermer, Ueber eatsehung und Verbrettung des abd ominaltyphus (Samml. Klin. Vort., No. 53, 
1873. — Cousot, Etude sur la nature, l'etiologie et le traitement de la fieVre typhoide, Bruxelles, 1874. — W. 
Budd, Typhoide Fever, London, 1873. — Bouchard, Etiologie de la fievre typhoide, Cong-res medical interna- 
tional de Geneve, 1877.— Van den Schrieck (de Hal), Du virus typhoide et de son ro'.e dons les epidemies, 
Bruxelles, 1875.— Pages, Etude clinique sur l'etiologie de la fievre typhoide, Paris, 1878. 
§24 



370 ON THE TREATMENT OF TYPHOID FEVER. 

us away from our subject. I shall only call your attention to the action of 
oxygen on all putrescent materials floating in sewers — an action which Fauvel 
has clearly shown in making it plain that this oxidation is a veritable combus- 
tion, which rapidly destroys the infectious element in night-soil; and we see in 
this an explanation of the fact that the South and East, despite their deplorable 
hygienic conditions, manage (by free exposure of their filth to atmospheric air) 
to keep tolerably free from epidemics. Although Rochard has affirmed that it 
would be easy to develop typhoid fever by the simple fact of massing people 
together in close quarters and under bad hygienic conditions, I believe that this 
overcrowding is a more powerful factor of typhus exanthematicus than of abdo- 
minal typhus. I make the same reserves in reference to the subject of alimen- 
tation as the determining cause of ileo-typhus. Wernich, 6 comparing the 
bacillus of typhoid fever with that of putrefaction, has ably maintained that the 

rejecting both fixed and movable fossae, and the " separative "or " diluent " apparatuses, and 
sanctioned the following resolution: 

" The flow in toto of excrementitious matters by sewers may be authorized in sewers 
largely and constantly fed by running water, which does not allow an accumulation of sand 
and dirt, and in which these effete matters shall be carried without obstruction or delay to the 
terminal distributing depot." 

The sewer waters carrying excrementitious matters, ought to be submitted to the process 
of purification by the soil. This purification may take place without danger to the public 
health, (a) 

6 The bacillus of typhoid fever being, according to Wernich, very similar to the bacillus 
of putrefaction, may be only a variety of the latter under peculiar circumstances of culture. 
Starting from this principle, he proposes the following distinctions between the typhoid 
fevers: 

i. The typhoid fevers by contagion which are due to the introduction of the bacillus 
and of spores from typhoid subjects. 

2. The typhoid fevers occasioned by aliments in the processes of decomposition. 
These fevers are determined by the bacteria of putrefaction which are found in unhealthy or 
spoiled meat. 

3. The endemic typhoid fevers due to putrid emanations of sewers, marshes, in a 
word, to the products of organic decompositions set free from the soil. 

4. Idiopathic typhoid fevers: an alimentation exclusively animal in too great abund- 
ance and especially the bad digestion of such food, determine in the stomach the putrefac- 
tion of the latter, and from this cause the presence of the bacillus of typhoid fever. 

With respect to treatment, there are two indications to fulfill, the causal indication and 
the symptomatic indication. With respect to the causal indication, it varies with the symp- 
tomatic indication. The typhoid fevers due to spoiled food, or to too abundant alimentation, 
demand the employ of purgatives, of calomel, and the internal use of antiseptic substances. 
The fevers due to contagion and endemic influence are tributary to treatment by quinine 
and salicylic acid. Idiopathic typhus claims purgatives and a strict dietary regimen. 

The symptomatic indications ought to be fulfilled by an alimentation from which should 
be excluded albuminoid or azotized substances, such as meat, eggs, milk, substances in 
which the bacillus develops with greatest facility; for drinks, pure water, or spirits and 
water, are recommended, (b) 



(a) Society d'hygiene publique et professionnelle, 1882. — Congres international d'hygiene, Geneve, 1882. 
-Travaux de Paris, commission technique de l'assainissement de Paris, 1883. 

(b) Wernich, Studies and Observations of Typhoid Fever (Zeitsch. f. Klin. Med., IV and V). 



ON THE TREATMENT OF TYPHOID FEVER. 371 

use of spoiled meats is a cause of typhoid fever. It has also been asserted that 
the use of water polluted by organic detritus, and that even milk contaminated 
by water of bad quality, might also be a cause. 1 I consider all these circum- 
stances as adjuvants; but no one of them alone seems to be sufficient as a 
determining cause of this disease. It is the same with geological conditions. 
The doctrine which is supported by Pettenkoffer and Buhl, attributes epidemics 
of typhoid fever to a lowering of the stratum of subterranean water. Observa- 
tions have in fact demonstrated that if this theory is conformable to what has 
been observed at Munich, it is not applicable to epidemics in other parts of 
Europe. 5 

As you see, gentlemen, it is not yet proved that any of the causes just 
alleged may spontaneously give rise to typhoid fever; and I am ready, for my 
part, to give my adhesion to the parasitic theory of this affection. It is true 
that this doctrine of contagium vivum denies all spontaneity, but it enables us to 
explain — thanks to the theory of vaccination (or, if you prefer so to put it, of 

1 It is in England that attention has been especially called to milk as an agent of con- 
tagion in typhoid fever. Hart, Russel, Cameron, Button, Murchison, have observed 
epidemics developed by the use of milk brought from a farm or habitation where were 
dwelling patients affected with typhoid fever, (a) 

2 In 1865, Buhl remarked that at Munich a large mortality from typhoid fever coincided 
constantly with the. lowering of subterranean water level. On examining, by the aid of 
statistics, the mortality of typhoid fever, Pettenkoffer found there complete confirmation of 
the opinion put forth by Buhl, and declared that "these mountains (meaning typhoid fevers) 
coincided with the valleys" (meaning lowering of the stratum of subterranean water) — a 
somewhat picturesque expression. Thus it is, for example, that in 1872 there were observed 
at Munich, in January, 60 deaths from typhoid fever, the level of the waters of the wells 
being 4^ metres below the surface, while only 18 deaths were observed during the month of 
July, when the level of the well water was only 3^ metres. 

Different explanations of this fact have been given. According to some, when the 
level of the water-bed is lowered, the fermenting detritus which impregnates the upper 
strata of the soil soaks, as by a natural drainage, into the wells and reservoirs of drinking 
water, carrying with it germs from the stools of typhoid patients, issuing from sewers badly 
calked, and fouling the water destined for alimentation. When the level of the underground 
water, on the other hand, is higher, as, for instance, after rains, the organic detritus of the 
soil is diluted and bathed with water constantly renewed, which stops further fermentation. 
This theory is still defended by Liebermeister, Buchanan, de Renzy, Hoegler, and Geissler. 

Buhl and Pettenkoffer do not take this view. According to them, when the waters are 
low, miasms are disengaged from the soil, and gain the atmosphere. The air of the 
miasms being generally warmer than the exterior air, acts in rising the part of a cupping 
apparatus, and aspirates, as it were, the germ-laden water from the soil, and this takes place 
the more readily since the barometric fall, which almost always coincides with the lowering 
of the subterranean water-bed, facilitates this gaseous liberation. Pettenkoffer adds that it 
is, in his estimation, probable that since the respiratory surface is larger than the diges- 
tive surface, the typhic poison behaves after the fashion of some other infectious poisons, 
and is absorbed by the respiratory rather than by the digestive passages. The dispute is 
far from being terminated between the partisans of the first of these theories (infection by 
water) and those of the second (infection by the air of the soil). Moreover, the basis of 



(a) Hart and Corfield, Medical Times and Gaz., april 1873. — Russell, Glasgow Med. Journ., april, 1872. 
■^-Cameron, Dubl. Journ. of Med. Sc, november 1873.— Button, Lancet, September 1873. 



372 ON THE TREATMENT OF TYPHOID FEVER. 

preservation by attenuated virus), it enables us, I say, to explain the immunity 
of typhoid patients from all future attacks of the disease. It enables us, also, 
to understand the comparative immunity of individuals who have long lived in 
Paris as contrasted with those who have lived there but a short time; the first 
having acquired, by long exposure to the virus, constitutional modifications 
which prove a relative protection. 

It enables us, moreover, to hypothesize atmospheric or telluric conditions, 
favoring in some degree the culture of germs of the typhoid contagion, without 
being compelled quite to indorse the explanation which Ernest Besnier has 
given of the march in accordance with seasons of the dothinenteric epidemic. 3 

But, on the other hand, this theory of living contagium leaves in obscurity 
many points in this interesting part of etiology, and in particular the epidemic 
character of this affection, and the special features which distinguish each epi- 
demic — circumstances which render so difficult the application of statistics to 
the study of the therapeutics of typhoid fever. Nevertheless, despite these re- 
serves, I adopt the theory of contagium rather than that of miasm. 

From the facts which I have just set forth, flow very important hygienic 
applications, some concerning public hygiene, into the consideration of which I 
shall not enter, others concerning private hygiene, and which in their totality 
constitute the hygienic and the prophylactic treatment of typhoid fever. As it 
seems to be absolutely proved that the typhoid virus is found in the fecal mat- 
ters of persons suffering from the disease, and that water polluted by these de- 
jections is the most powerful factor of the contagion, it follows that it is a duty 
thoroughly to disinfect these alvine dejections, and the objects which they have 
polluted. It follows, also, that one should have a careful surveillance of pot- 
able water, and, if not certain of its purity, such water should be boiled before 

the discussion is far from being indisputable, and Dr. Albin has well said that the exceptions 
to the aphorism of Munich (Munchener aphorism) are so many that one may almost main- 
tain the contrary aphorism, i. e., to a rise in the subterranean water-level, corresponds an eleva- 
tion in the number of typhoid cases. Similar cases have also been noted by Liebermeister, 
Ruitmeyer, and Louis, [a) 

3 Ernest Besnier has formulated the following laws, basing himself upon the march of 
typhoid fever these last two years in the hospitals of Paris : 

Typhoid fever prevails according to seasons. It finds a habitat in every soil where 
man dwells, but France is its favorite seat. 

In Paris typhoid fever reigns permanently. It carries off every year 1200 of the Parisian 
population, a mortality which supposes from 7000 to 10,000 typhoid cases in Paris each year. 

Of 100 deaths, there are 17 in the spring and 37 in the fall. In July and August the 
mortality rises suddenly to descend in November and December, and reach its minimum 
in June. 

Such is the law ; there are few exceptions, and these do not materially change it (b). 



{a) Buhl, Erne Beitrag zur CEtiologte des Typhus (Zeitsch. fur Biol., 1865, B. I, p. 1).— Pettenkofer, 
Ueber die Schwankungen der Typhussterblichkeit in Miinchen von 1850, bis 1857 (Zeits. fiir Biol., 1868, et 
Ueber die CEtiologie des Typhus, Miinchen, 1875. — Liebermeister, Deutsch. Klin., 1866. — Buchanan, 
Lancet, Janvier 1873.— De Renzy, Lancet, juin, 1873. — Hoegler, Deutsch. Arch., 1873,1. XI, 257.— Geissler, 
Bericht liber den typhus. — Liebermeister, Handb. voa Ziemss., 1854, p. 73. — Albin, Zeitsch. f. Epid., 1874, 
p. 270. 

{b) E. Besnier, Comptes rendus de la Societe des hopitaux, from 1865 to 1883. 



ON THE TREATMENT OF TYPHOID FEVER. 373 

being used, or some of the table waters should be employed, such as Apolli- 
naris. Moreover, I refer you in this connection to the instructions issued by 
the Council of Hygiene, of which I am a member, concerning the measures to be 
taken to stay the progress of the epidemic of typhoid which raged over this 
city in 1882. 1 

So much for the prophylactic treatment. The hygienic treatment is of 
capital importance, and the more you see of this disease the more you will ap- 
preciate its importance. Under this head I shall examine, successively, the 
dietary regimen, the measures to promote cleanliness, and the care of the sick- 
room. 

For the severe and cruel regimen of Broussais, who opposed feeding fever 
patients, we now substitute the administration of nourishment as a necessary 
part of the treatment, and no disease so markedly shows the advantages of 
generous alimentation. You must, then, feed your typhoid patients ; but, re- 
membering the disease of which the digestive tube is the seat, you should exer- 
cise great care in the choice of nourishment, which should be chiefly liquid ; 
and every substance should be prohibited which might become a source of 

1 These are the rules adopted October 19, 1882, by the Council of Hygiene and of 
Salubrity of the city of Paris, concerning the precautions to be taken in the event of the oc- 
currence of typhoid fever : 

When a patient is found to be affected with typhoid fever, it is well to adopt the follow- 
ing hygienic measures : 

1. Isolation. — The patient must be isolated as much as possible from the other inmates 
of the house. 

If the situation does not permit sufficient isolation, it is better to remove the patient to 
the hospital. 

If the patient remains at home only those persons should be allowed to enter his room 
who are necessary to give him the requisite care ; and all children and youths should be 
rigorously excluded. 

All nurses and attendants should be required to bathe themselves with carbolic water 
(2^ drachms to a quart of water). 

2. Aeration of the Sick Room. — The sick room ought to be well ventilated. All tapestry, 
window curtains, and carpets should be removed. The bed should as far as possible be placed 
in the middle of the room. All the dejections of the patient before being carried out of the 
chamber to the privy should be completely disinfected by a solution of chloride of zinc (50 
grammes — about 1% oz. — to the quart of water). This solution should also be employed in 
thoroughly cleansing the cloaca every time that the dejections are thrown into it. 

3. Disinfection of the Clothing — All the body clothing, all the bed clothes, that have 
been used about the patient, ought before being taken from the sick room to be soaked in a 
solution of phenic acid (5 drachms to the quart of water) ; they should then be immediately 
given to the washerwoman. 

4. Purification of the Boom. — After the recovery or death of the patient there should 
be placed in the sick room, on a bed of sand, an iron kettle containing red hot coals, upon 
which should be thrown a quantity of sulphur proportional to the capacity of the rooms — 5 
drachms to every cubic metre. The room should be thus thoroughly fumigated, and should 
remain closed for 24 hours. 

This having been attended to, the bedding and clothing in this room should be cleansed 
with the greatest care. 

The room should be thoroughly washed with carbolized water (5 drachms to the quart), 
and it should not be occupied till after having been aerated for at least one week. 



374 ON THE TREATMENT OF TYPHOID FEVER. 

irritation in the alimentary canal. Give your patients, then, milk, broths, well- 
strained gruels, and stimulating drinks, such as wines and vinous lemonades. 
These beverages constitute the only drinks permissible. I make exception of 
plain lemonade, which, without possessing any marked anti-febrile properties, 
is always refreshing to fever patients. 1 When there exist gastric disturbances, 
and you wish to support the patient, you may give iced champagne. It is 
generally a good thing to add ice to the ordinary drinks of the patient. 

But the time when you should redouble your watchfulness is when you 
come to the convalescing period of the disease. During convalescence, the 
patient either has a ravenous appetite or he has no appetite at all. Where 
appetite exists and is imperious, you will have to exercise rigorous care in pro- 
hibiting too free indulgence in all kinds of food. For my part, I have three or 
four times in my life seen convalescent patients die from excessive eating. I 
remember well a patient in the Hotel Dieu, where I was attending, who was 
convalescing from a very severe attack. He went out of the hospital, and the 
first thing he did was to help himself to a hearty meal. The next day he came 
back to the hospital with all the symptoms of peritonitis, from which he died. 
The autopsy revealed an intestinal perforation. You should have such facts 
always in mind when you direct the dietary of fever patients during their con- 
valescence, and although the instinct for food at such times is a natural one, 
the utmost judgment is required in its gratification. 

In other cases, there are anorexia, vomiting, and dyspepsia; symptoms 
which, as our colleague, Anatol Chauffert, 2 has well shown in his thesis on the 

1 The lemon (citrus limonum) is of popular use among the Arabs in intermittent 
fever. The therapeutic properties of the lemon were especially vaunted by Mohammed, 
and the Arab physicians have added but little to what he has said. Moreover, Ishac-Ibn- 
Amraw says that the decoction of the pulp of the lemon is especially advantageous in fever. 
In Greece the lemon is, likewise, emplo3^ed as a febrifuge ; and in Guadeloupe they make 
use of the powder of the bark of the citrus root in fevers. 

Maglieri, in Italy, has made trials of this fruit in malarial fevers, and has found a de- 
coction of the lemon to be beneficial. He thinks it even superior to preparations of cin- 
chona. This is the way that Maglieri prepares the decoction : The fresh lemon is cut into 
small slices, and infused in three teacupfuls of hot water down to one cupful, strained, and 
expressed through a linen strainer, and cooled in the open air.(«) 

2 Cruveilhier has called attention to congestions and haemorrhages of the gastric 
mucosa in patients affected with typhoid fever. Others have noted erosions of the stomach, 
and such instances will be found mentioned in the works of Louis, of Jenner, Rilliet and 
Barthez. Hamerinsk has observed fibrinous exudation in the pyloric region. Millard, 
Josias, Collingwood have noted similar cases. 

Chauffert has united all these facts under the name of ' ' gastric degenerations of typhoid 
fever." The gastric alterations are characterized especially by lymphatic lesions of the 
stomach, constituting veritable confluent abscesses, by vascular stases and by degenerations 
of the gastric glands. All these lesions manifest themselves by vomiting and by pain in the 
region of the stomach. (3) 



{a) Bertheran, Du citron dans les fievres intermittentes (Journ. de med. de V Algerie, aout 1883, p. 177). 
-Maglieri, Giorn. diclinica e tempia^xaax?, 1883. — Cazin, Traite des plantes medicates indigenes. 

(b) Studies on the gastric determinations of typhoid fever. These de Paris, 1832. 



ON THE TREATMENT OF TYPHOID FEVER. 375 

gastric complications of typhoid fever, depend on the alterations which the gas- 
tric mucous membrane has undergone from the typhoid process. Here we 
must apply all the measures which are addressed to the treatment of ulcerous 
gastritis— a diet of pure milk, which gives rest to the enfeebled stomach, milk 
punch with meat powder; this is an excellent way of giving this highly nutritive 
preparation. 1 It may, finally be necessary to resort to lavage of the stomach 
and to forced feeding. 

It is not enough to support your patients; there must be the most scrupul- 
ous care about cleanliness, and it will not do to allow them to be denied by 
their urine or alvine dejections. In the curious and interesting narrative which 
Dr. Stewart has given of his personal experience in an attack of typhoid fever, 
he alludes to the disagreeable sensations which the delirious patient suffers 
from the wet, soiled underclothing in contact with his body, as well as from in- 
tense light and loud noise. You can promote this cleanliness of the person 
and the healthy action of the skin by frequently bathing the entire surface with 
cold or tepid water containing a little thymol or antiseptic vinegar. These 
lotions not only keep the patient clean, but they also lower the temperature 
and diminish that sensation of heat and dryness so painful to fever patients. 
These antiseptic spongings should be repeated two or three times a day. 

As for eschars and ulcerations of the skin, they may be prevented by fre- 
quently changing the position of the patient, who must not be allowed to lie all 
the time on his back; and it is always a good plan, where the patient can afford 
it, to have the bedclothes upon which he lies made of silk instead of cotton, or 
else to provide him with a water bed. 

Your attention ought to be called to the condition of the mouth and throat 
of these patients — a matter of considerable importance. 2 You should urge the 
attendents several times a day to cleanse the teeth and gums of the sordes 
which collect upon them, and you must insist that they keep the tongue 
moist ; there is nothing better for this purpose than the alkaline waters 
of Vichy and Vals. This dryness of the tongue is one reason 
why it is so hard for the typhoid patient to talk, and you can only rid him of 
this inconvenience by cleansing applications and gargles. 

You have seen the great importance which is placed on disinfecting the 
stools of typhoid patients. These dejections, besides the contagious principle 

1 Meat grog is made in this way: Into an ordinary bowl you place two teaspoonfuls 
of meat powder and add two tablespoonfuls of old rum, which may be sweetened to the liking. 
Mix thoroughly together and pour on sufficient cold milk to make a thin liquid mixture. 

When the patient cannot bear the alcohols, you dissolve the meat powder simply in 
milk, sweeten the whole with sugar, and flavor with vanilla. 

These mixtures may be varied to an indefinite extent, but the essential condition is to 
administer them cold. 

2 Nelter, of Nancy, has suppose i that the typhogenous miasm penetrates by the mouth 
and nasal fossae, and that by its progressive march it determines successively bronchitis and 
diarrhoea. One may, according to him, by constant cleansing of the buccal and pharyngeal 
cavities, destroy the miasm and arrest on the spot the typhoid fever, (a) 



(a) Nelter, Gaz. des hop., 1873 



376 ON THE TREATMENT OF TYPHOID FEVER. 

which they contain, have a marked gangrenous odor, which poisons the room 
of the patient; there is, then, a double necessity for prompt disinfection. You 
can accomplish this by allowing the fecal matters to be passed in a vessel con- 
taining a certain quantity of a two-per-cent. solution of the sulphate of zinc, 
copper, or iron, and in taking care also to cleanse with the same solutions all 
water-closets receiving these dejections. Lavements — and I speak here only of 
disinfectant lavements — have also the same object. One of the best and most 
inoffensive is that recommended by Bouchard, and which consists of a mixture 
of powdered charcoal in water, in the proportion of two or three spoonfuls to 
the pint. These lavements cause no trouble, and have the advantage of des- 
troying the nauseous smell of the fecal matters. 

You should also examine with great care the urinary functions of your 
patients. You know, in fact, how frequent is retention of urine in typhoid 
patients, and that, in consequence of the delirious condition in which they are 
plunged, they are frequently unable to express their natural wants. You 
should, then, frequently examine the abdomen, and resort to catherization when 
you find that the bladder is not thoroughly emptied. 

It is not everything to have directed the alimentation of your patient, to 
have minutely indicated all the pains that should be taken for cleanliness and 
disinfection; you must also furnish indications no less precise concerning the 
ventilation of the sick-room. You should choose a room which is well aired 
and ventilated, and place the bed of the patient in the middle of this room; the 
bed should be narrow, moderately elevated, and divested of curtains and all 
canopy, so that the attendants can readily and rapidly wait on the patient. If 
in your power to do so, you should choose two rooms adjoining each other, so 
that the patient may alternately be transported from one to the other. You 
should allow but a modicum of light to enter this room, and no lamp should be 
kept burning in the night-time. Strong light is painful to the typhoid patient 
and favors the delirium. But few persons ought to remain in the room; one 
commonly suffices. Urge on the attendants the importance of keeping silence, 
and if they must converse, let them do so in an undertone. Stewart, in the 
narrative of which I have just spoken, dwells much on the painful sensations 
which he experienced when loud conversation was going on in his room. 

Generally, the delirious manifestations do not acquire a high intensity; 
nevertheless, there are cases in which there exists a veritable delirium of action, 
and which necessitates forcibly keeping the patient in his bed. It is best in 
these cases, as far as possible, to accomplish this by the aid of the persons who 
attend the patient, and not resort to rigorous measures of restraint, such as the 
strait-jacket, unless other means fail. By the strangulation which it imposes, 
by the absolute and continuous dorsal position which it necessitates, by the 
pressure which it exerts on the thorax — the strait-jacket favors the visceral con- 
gestions so frequent in this fever, and may even be a cause of death, as I have 
several times witnessed in my hospital service. 

Apropos of this typhoid delirium, and without departing from the hygienic 
ground which we now occupy, I cannot too much recommend you to cut the 
hair of your patients, especially in the case of young females, who are apt to 



ON THE TREATMENT OF TYPHOID FEVER. 377 

have long, thick hair. This is the more needful where there is much mental 
disturbance. I have often observed considerable improvement in the delirious 
manifestations by cutting the hair; and this cannot be much of a sacrifice to 
patients who reflect that their hair will all fall out in the course of convalescence. 

You will, perhaps, think, gentlemen, that I have gone into too many little 
details about the hygienic management; but all these points have their import- 
ance, and I can affirm that typhoid fever well nursed is half cured. The neces- 
sity of careful attention to hygiene is exemplified in the difference in mortality 
which obtains between hospital and private practice; for in our hospitals we are 
not able, by reason of the peculiar conditions in which we are placed, and 
especially from want of sufficient nurses, to apply these hygienic rules as thor- 
oughly as we would like. Therefore, I earnestly recommend you in your 
private practice to attend scrupulously to the minor as well as the major details 
of hygiene. How many severe typhoid cases have I seen which owed their re- 
covery to these hygienic means alone, and to the faithful services of some 
friendly attendant — rendered with that devotion and that self-sacrifice which 
are only to be found in the bosom of the family! 

I pass now to the proper medical treatment of the disease. I shall com- 
mence by reviewing the different kinds of treatment which have been in vogue; 
then we shall examine the approved medicinal measures, and the indications 
for their employment during the regular course of the fever and during the 
complications. 

The different kinds of treatment of typhoid fever may be arranged in three 
principal groups. In the first, it is the fever alone which demands attention; 
in the second, it is the typhoid poison or miasm which is to be combated; in 
the third, it is empiricism which has directed the treatment. Hence we will 
examine successively the antipyretic treatment, the parasiticide treatment, and 
the empirical treatment. 

We find in the antipyretic medication the same divisions as in the previous 
chapter, viz,, we shall have to examine successively refrigerants and antipyretics. 
Refrigerant medication has found in the treatment of typhoid fever one of its 
principal applications, and we shall have to study here, cold baths, tepid baths, 
refrigerant apparatus, cold affusions, and lavements. 

There is no question in therapeutics which has of late years provoked 
more vehement discussion than that of the application of cold baths to the 
treatment of typhoid fever; and this method to which Brand has justly given 
his name, for he it is who has furnished it with a rigorous and mathematical 
formulation, has been attacked and defended by resolute adversaries and de- 
termined partisans. I myself have taken part in this debate, and I am going 
to set forth as impartially as possible the advantages and disadvantages of this 
method. 

Brand has thus formulated the treatment by cold baths: "You must ad- 
minister baths of 64 to 68° F. of fifteen minutes' duration, from the fifth day of 
the fever; these must be repeated day and night every three hours, as long as 
the temperature of the rectum exceeds 102 F." In applying rigorously this 
method, so simple in appearance, Brand considered himself warranted in af- 



378 ON THE TREATMENT OF TYPHOID FEVER. 

firming, that every case of typhoid fever treated regularly from the beginning by 
cold water, will be exempt from complications, and will get well. 

I shall not here enter into the details of Brand's method, details which pertain 
to the manner in which the patient should take the bath; and I refer you in this re- 
gard to the minute directions which Dr. Chapuis has given in his thesis (Paris, 
1883), and which are founded on the technics in usage in the hospitals of Lyons. 1 
Lyons is, in fact, the only city in France where Brand's method is used in all 
its rigor, under the persevering efforts of Dr. Glenard, who, during his capti- 
vity at Stettin, had an opportunity to witness the results which Brand was ob- 
taining. Dr. Glenard must congratulate himself on the success which has at- 
tended his persevering efforts, for we see almost complete unanimity in the 
hospitals of Lyons in reference to the refrigerant medication. 2 

1 This is how, at Lyons, Brand's cold bath treatment is carried out: The baths 
are not given at the bedside of the patients, but they are carried into a special bath 
room. The transportation is made on arm-chairs provided with wheels and well padded 
with rubber cushions. The windows of the bath room are closed at all times, even in 
the summer. The door is also kept tightly shut during the period of immersion in the 
water. 

As soon as the patient enters the bath, the nurse gives him a cold affusion on the 
head with water from 43 to 46 ° F. This water has been cooled with ice; the tempera- 
ture of the water in the bath varies from 64 to 68° F. If the delirium is intense, the 
affusion is of longer duration, and the water is projected from some height; during the 
whole duration of the bath the attendant looks out that the patient is kept immersed up to 
his neck in the water, of the bath tub ; not even the shoulders are to be allowed to re- 
main out of the water. Frictions are made up and down the upper limbs and over the 
chest; this massage is especially useful in the case of patients that are cyanosed. When 
first the chill becomes imminent (which generally happens at the end of ten or twelve - 
minutes) the patient is vigorously rubbed, and a few mouthfuls of wine are given. The 
bath lasts ordinarily about fifteen minutes in the case of adults, and six to eight minutes 
in the case of children. Before leaving the bath, the patient is subjected to another 
affusion of ice-cold water; this being over, he is wrapped up in a dry sheet and covered with 
a warm woolen blanket and returned to his bed without being wiped. The patient is then 
given some soup and several spoonfuls of wine; but Brand's recommendation is not followed 
out, viz., to give the febricitant a few swallows of cold water every quarter of an hour; it is 
considered better to let him rest. In cases where the meteorism is very marked, compresses 
of cold water are applied over the abdomen, and kept there permanently. (a) 

- It was Glenard who first, in 1873, introduced the method of Brand into the service 
of Faivre, physician of the hospital of La Croix Reusse. This physician having been made 
prisoner in 1870, had been able personally to observe, during his captivity at Stettin, the re- 
sults obtained by Brand. From July, 1873, to January, 1874, of 53 typhoid patients treated 
in the service of Faivre by the method of Brand only one died. The mortality by the other 
methods for the same year was 26 per cent. 

During the epidemic of 1874, an application of this treatment was made on a large 
scale, and in a series of 228 patients treated by cold water, it gave a mortality of 19 per cent. 
229 other typhoid cases treated by the ordinary method gave a lessened mortality of 10 per 
cent. 

A report made by Molliere apropos of Brand's method, covering 150 cases of typhoid 
fever treated at Lyons, furnished a mortality of 9 per cent, for the patients treated by 
Brand's method, and 5 per cent, for the patients treated in the ordinary way. Although the 



(a) Chapuis, Typhoid Fever and Cold Baths at Lyons. (These de Paris, i! 



$3.) 



ON THE TREATMENT OF TYPHOID FEVER. 379 

It is upon statistics that the partisans of this method base their arguments 
almost exclusively. Jaccoud, from a review of more than eighty thousand 
cases, arrived at an estimate that the average mortality in typhoid fever was 
19.23 per cent. 3 On the other hand, taking as a point of comparison the mili- 
tary hospitals, and in reckoning under a common title the continued fevers and 
typhoid fever, a mortality of 14 per cent, is obtained. The application of 
Brand's method has caused a considerable fall in the percentage of deaths, 
since, out of 30,000 cases treated by cold baths, there was a mortality of only 

report was not accepted by the Medical Society of Lyons, it had an unfavorable influence on 
the adoption of the cold bath system, which was abandoned from 1877 to 1881. In 1881 the 
method was again taken up, under the influence of Bouverel and Raynaud, and it has since 
then furnished results so satisfactory that 22 hospital physicians out of 24 have sent to the 
Academy of Medicine a declaration, stating that they are partisans of Brand's method of 
treating typhoid fever, with the experimental conviction that this method, regularly applied 
from the onset of the disease, considerably lowers the rate of mortality. They aver that 
they employ it in their families, in their hospital service, and in their private practice. 

The two physicians of the hospitals of Lyons who have not adopted the cold bath sys- 
tem are Teissier and Bondet. The first has obtained with the ordinary methods a mortality 
of 7.89 per cent. As for the second, in comparing the mortality of typhoid fever in the 
civil hospitals where Brand's method is carried out, and in the military hospitals, where re- 
course is had to other treatments, he has found that with respect to the first, out of 2609 
patients the mortality was 15 per cent., while with respect to the second, out of 3471 
patients the mortality was only 13.50 per cent. (a) 

3 Jaccoud has gathered statistics bearing on a total of 80, 149 cases of typhoid fever, 
and producing a mortality of 19.23 per cent. 

In the French army the mortality for the year 1876 was 45 per cent., and for the years 
1875 to 1879, 37.41 per cent. If you add to the figures of typhoid fever those entered as 
continued fever (as Colin urges), the mortality then falls to 14 per cent. 

Brand, in his statistics of 335 patients, claims a mortality of only 4.6 per cent. Only, 
while 2ir patients of the civil statistics (private patients) have furnished no deaths, 124 
patients treated in the hospital have given a mortality of 12 per cent. In bringing together 
statistics representing 8,141 cases where his method has been applied, the writer arrives at 
a mortality of 7.4 per cent, in the hospital wards. 

Glenard affirms that the mortality of the cold water treatment, taking as the basis of 
his calculation 30,000 cases of typhoid fever treated in France and Germany, falls to 9 per 
cent, ; while in certain military Pomeranian hospitals the mortality is not more than from I 
to 2 per cent. 

The results obtained at the civil hospital of Munich, from 1868 to 1875, where Brandt 
method has been applied in all its rigor, in 2,223 cases have given, according to Ziemssen, a 
mortality of 9.2 per cent., and at Zaubzer a mortality of 8.8 per cent. These figures come 
very near to those given by Brand himself. 

Strube, physician in chief and director of the health department in Prussia, affirms that 
in the military hospitals of the commandery at Stettin, constituting ' the second corps of the 
army, the mortality falls to 8.7 per cent, where the method of Brand is rigorously applied ; 



(a) Glenard, Du traitement de la fievre typholde paries bains froids a Lyon, de juillet 1873 a Janvier 1874 
(Lyon med, 1874).— Humbert Molliere, Rapport sur le traitement de la fievre typholde par la methode de 
Brand (Lyon med ., no 4? et 43, 1876).— Mayer, Resultats compares du traitement de la dothienenterie par la 
methode de Brand et par les meYnodes ordinaires (Un. me'd., novembre 1876 ; Lyon med., no 51, 1876.) — Bon- 
det, la Fievre typholde el les bains froids a Lyon pendant l'epidemic de 1874 (France med., juillet 1874). — Ed- 
mond Chapuis, la Fievre typholde et les bains froids a Lyon (thdse de Paris, 1883).— Bondet et Teissier, Acad, 
de m6d., decembre 1882. 



380 



ON THE TREATMENT OF TYPHOID FEVER. 



nine per cent., and in the case of the military hospitals, of only seven per cent. 
or even lesb: ; and, if we may rely upon the figures furnished by Abel, physician 
in chief of the second corps of the Prussian army in Pomerania, the mortality 
was reduced to nothing. 

What is the real value of such captivating figures as these ? You know 
already my opinion concerning statistics as applied to therapeutical results — I 
expressed them very clearly while on the treatment of pneumonia — I have not 






while in the thirteenth corps, where this method is not adopted, the mortality is 31 per cent. 
He claims that a whole battalion may thus be saved every year to the army, and, in three 
years, a regiment. 

Abel, physician to the second corps of the army in Pomerania, goes still farther. Ac- 
cording to the statistics which he has collected, the mortality of 15.9 per cent, before the 
adoption of Brand's method has fallen to o since the adoption. 

Schmidt, of Erlangen, at the same time, has presented statistics of treatments by cold 
baths, which are as follows : 

Mortality. 

From o to 15 years o per cent. \ 

,, 161030 ,, 10.1 ,, ,, I 19.6 per cent. 

,, 31 to 45 ,, 29.1 ,, ,, ) 

Goltdammer, who rigorously applies Brand's method to the treatment of typhoid fever 
at the Bethany hospital of Berlin, has furnished the following statistics. 



Years. 


Cases. 


Deaths. 




1868 


220 


23 


10,4 per cent 


1869 


182 


20 


11. 9 .. » 


1870 


126 


14 


11. 1 11 


1871 


186 


22 


11. 8 „ ,, 


1872 


350 


40 


11. 4 ., ,, 


1873 


239 


27 


11. 3 „ ,, 


1874 


245 


45 


18.3 „ „ 


1875 


333 


56 


16.3 ,, ,, 


1876 


205 


29 


I4-I M I- 


3-1876 


2,086 


276 


13.2 ,, ,, 



These statistics continued by his assistant Gesenius, until 188 1, give the following re- 



sults 



Years. 


Cases. 


Deaths. 




1877 


236 


35 


14.0 per cent 


1878 


160 


23 


14.4 ,, .. 


1879 


159 


18 


11. 3 ., 1, 


1880 


289 


47 


16.3 „ 1, 


1881 


210 


24 


114 ,, ,, 



1877-1881 



1,054 



147 



39 



(a) 



(a) Jaccoud, Traitement de la fievre typhoid [Fac. de med., 28 et 30 novembre, et Acad, de tned., 1883J. 
—Colin, Traits des maladies epidemiques et recueil des me'moires de medecine militaire, Janvier, 1882, et Acad 
de med., seance du 23 Janvier, 1883 — Brand, Die Hydrotherapie des Typhus, Stettin, 1863 ; Die Heilung des 
Typhus, 1868 ; Die Wasserbehandlung der Typhoesen Feber, Tubingen, 1877, p. 280 et 281. — Frantz Glenard, 
Sur le traitenent de la fievre typhoide par les bains froids [Acad.de m£d., stance du 9 Janvier, 1883].— Du 
traitement de la fievre typhoide par les bains froids a Lyon, juillet, 1875, Janvier, 1874 [Lyon me"d., p. 142, 220, 
34g, 415, etc., etc.]. 



ON THE TREATMENT OF TYPHOID FEVER. 381 

changed my mind, and I persist in considering statistics as an unreliable cri- 
terion of the results of our treatment, because, in order that this method may- 
give positive results, it is essential that the individual cases which are collected 
and compared together shall be proper subjects for comparison, a thing which 
does not happen in pathology. Take, for example, typhoid fever. Do you 
believe that one typhoid patient is exactly like another typhoid patient ? The 
age of the patient, the state of his vital forces, the relative severity of the epi- 
demic, the period of the year, the nature of the locality even, have a great in- 
fluence on this pathological aggregate, and modify its march and its fatality. 
It is here, especially, that we see the influence of what I have called the morbid 
genius of epidemics, where one sees epidemics relatively benign, succeed epi- 
demics that were relatively malignant ; and according as you apply the same 
method of treatment to the first or to the second, you will have multiplied suc- 
cesses or failures. 

The arguments, gentlemen, which I adduce against statistics, I can in turn 
obtain from statistics themselves, and to the figures so convincing of Brand, of 
Glenard, of Strube, of Abel, etc., I need only oppose those of Schmidt, of 
Erlangen, of Goltdammer, of Berlin; of Boudet, of Lyons, which show us that 
by rigorously employing the cold bath medication, the rate of mortality is con- 
siderably increased, approaching, as it does, a mean of 19 per cent., and even 
exceeding this sometimes. I might even compare the other methods of treat- 
ment with that of Brand, and show you also by figures that the refrigerant 
method has nothing to boast of. 

I know well the objection which the partisans of the cold bath cure make 
to these last statistics. They tell us that in these cases Brand's system of treat- 
ment was not carried out with mathematical precision, and according to his 
rules, and, what is of more importance, it was not employed from the very com- 
mencement of the disease. My reply to the objection is more formal, and I 
assert that in the majority of cases, and outside of military practice — for which 
I make some reservation — the method of Brand is impracticable, both in our 
hospitals and in private practice. Not that I believe we cannot, in our hospi- 
tals and in our ordinary practice, succeed in giving, despite the difficulties 
which attend them, cold baths day or night to our patients, but because it is 
necessary, according to Brand, to give these baths before the fifth day of the 
disease. Never do patients enter our hospitals at this period, and when they 
do enter, as we cannot be sure of our diagnosis till after the seventh day, it is 
not till this date that the cold bath treatment can be commenced. 

To this objection Brand's partisans have replied categorically, and Bard 
has given the reply in this concise form : " In order that the method of Brand 
may have full efficacy, all fever patients should, without distinction, be sub- 
jected to the bath ; the bath will know its own." I do not know if the bath will 
"know its own" or not; but what I do know is, that we cannot, without 
danger, subject all our fever patients to a rigorous and severe method, and 
when we are ignorant of the cause even of the febrile process. Do you believe 
that the cold bath may not determine profound congestions ? Do you believe 
that you can thus, without danger, force the circulating blood from the 



382 ON THE TREATMENT OF TYPHOID FEVER. 

cutaneous surface to the central parts ? My colleague and friend, Dumont- 
pallier, has well argued that the slow and progressive refrigeration does not 
provoke visceral congestion ; but to the clinical and experimental facts to 
which he appeals, I have opposed experiments and observations absolutely con- 
trary to these views. Brand's method, whatever one may say, is not free from 
danger, and not a few of the complications which supervene on the part of the 
lungs or intestines, in patients submitted to this treatment, may be attributed to 
it. As for the pulmonary liabilities, there is no doubt that as a result of the 
cold bath medication congestions and inflammations of the lungs have arisen ; 
and during the discussion which took place in 1876 and 1877, in the Society of 
the Hospitals, this fact greatly impressed the majority of those who took part 
in these debates. 1 

I must say as much as regards intestinal hemorrhage ; I believe that in 
certain cases the cold baths may favor these hemorrhages in patients who are • 
predisposed. 2 These complications, moreover, on the part of the lungs and 
intestines, are quite explicable from the very action of the cold baths which are 
employed. 

Where do you suppose the blood goes to which circulates at the periphery 

1 Hagenbach affirms that pneumonia occurs in typhoid fever treated by the ordinary 
methods in 20 cases out of 100. 

Brand, basing himself on the statistics of Jurgensen, of Scholz, and of Stecher, as well 
as on his own, arrived at a medium of 7.2 per cent, for the cases of pneumonia after the 
employment of refrigeration. 

At the same time the statistics of Liebermeister are even more favorable, as lobar and 
lobular pneumonia occurred 70 times out of 861 cases of typhoid fever before resort was had 
to Brand's method, that is to say in 7 per cent., and since the application of cold baths there 
have been but 50 cases of pneumonia in 559, i.e., 6.4 per cent. 

In France these complications have been oftener observed. Potain, Raynaud, Peter, 
and Fereol have noted pulmonary congestions and pneumonias produced by cold baths. (a) 

- Apropos of the frequency of intestinal hemorrhages in typhoid fever, Brand has ob- 
served but 155 cases out of 1,995 where cold baths were employed, i.e., 3.1 per cent. The 
statistics of Louis, of Ragaine, of Griesinger, bearing on 4,890 cases, give 771 cases of in- 
testinal hemorrhages, i.e., 5.6 per cent, under the ordinary methods. 

Lehnert has made the statement, with reference to Brand's statistics, that the latter 
made no account in those statistics of moderate hemorrhages. If the latter are reckoned, 
the hemorrhages would attain the figure of 5 per cent. Goltdammer, in comparing 5.636 
cases of typhoid fever treated by cold baths, with 13,653 treated by the ordinary method, 
with reference to the proportion of intestinal hemorrhages, observed these in 4 per cent, of 
the former cases, and 3.90 per cent, of the latter. 

To these statistics should be added those of Wunderlech (son) and Schultz, of Heidel- 
berg. The former observed at Leipzig 253 cases of typhoid fever ; 155 were treated with 
cold water — there were 16 cases of enterorrhagia, 10.3 per cent. ; of the other 98 cases, there 
were 2 of hemorrhage, i.e., about 2 per cent. 

Schultz has made a comparative study of the mortality in typhoid fever, as treated by 



(a) Brand, Wasserbehandlung der typhosen Fieber abdominal und flecktyphus, Tubingen, 2e edit., 
1877. — Fereol, Sur le traitement de la fievre typholde par les bains froids [Un. med., 18 decembre, 1876, ei Soc. 
des hop.,juillet, 1883]. — Raynaud, Du traitement de la fievre typholde par les bains froids a propos de l'epi- 
demie actuelle [Bull. gen. de ther., t. XCL, p. 433].— Robert, Etude sur les complications consecutive des 
traitements de la fievre typholde par la methode de Brand [these de Paris, no 160, 1877]. — Peter, les Bains froids 
coup sur coup dans la fievre typholde LUn. med., avril et mai, 1877]. 



ON THE TREATMENT OF TYPHOID FEVER. 383 

when it is driven inwardly by the vaso-motor constrictive action of the cold 
bath and ice-water lotions? The blood cannot find refuge except in the inter- 
nal organs, and this reflux cannot but favor congestion of the abdominal viscera. 
Soulier has made many experiments on animals to show that the vaso-motor 
constriction is produced almost at the same time at the surface and in the 
central organs; but I believe that these experiments, however careful they may 
have been, place the animal in quite different circumstances from those of our 
typhoid patients. 3 

To sum up, I consider the exclusive method of Brand, and the rigorous 
and mathematical rules which he has formulated, as deserving to be banished 
from the treatment of typhoid fever, and for this reason especially — because it 
requires, in order to derive from it all the results which it promises, to be ap- 
plied before the diagnosis can be certain; for, employed later, this system only 
gives — according to the acknowledgment of its most zealous partisans — results 
comparable with those of other therapeutic methods, and with greater danger to 
the patients. You will see, in fact, that we have for the treatment of certain 
manifestations of abdominal typhus, hydro-therapeutic means much less 
dangerous and quite as powerful — not, perhaps, from the point of view of 
hyperthermia, but from that of the other symptoms of typhoid fever; for, in my 
opinion, the advocates of the refrigerant medication have committed an error in 
vociferating, "The hyperpyrexia! behold the enemy!" The hyperpyrexia, as 
Peter has well said, does not constitute all the danger of the disease, of which 
it is only one of the manifestations. 

Tepid baths are, in my judgment, much more applicable to ordinary cases 
of this disease, and I pointed out several years ago the advantages which might 
be derived from these baths, which, as my hospital experience has shown, have 
an antipyretic action much less marked than that of cold baths, but are abso- 

the cold baths and by the ordinary medication. The method of cold baths gives only I per 
cent, in favor of this treatment. He has, moreover, noticed that intestinal hemorrhages 
were in the proportion of g.6 per cent., while with the other methods they occurred in only 
3.4 per cent. 

In France, Peter, Raynaud, Fereol, etc., have also noticed this greater frequency of 
hemorrhages, (a) 

3 Soulier plunged in water at a temperature of 8° to 14 C. (46 F. to 57°F.) hares and 
guinea pigs previously shaved in order to permit of refrigeration. After several minutes no 
elevation of temperature was indicated by a thermometer placed in the rectum. In another 
hare he dissected out and exposed the mucous membrane of the ileum; the animal was 
plunged into a bath of 15 C. without allowing the water to come in contact with the intes- 
tine. At the moment of immersion the mucous membrane became pale, and its capillaries 
appeared shrunken and empty, while vermicular movements were produced expelling the 
intestinal matters. ($) 



(a) Carl Wunderlich, Ueber Darblutungen bei Typnus abdominalis unter der Kaltwasserbehandlung 
[Diss, inaug., Leipzig, 1872].— Ch Deperet, De l'influence du traitement par l'eau froide sur la production de 
l'hemorrhage intestinale dans la fievre typhoide [these de Paris, 1876]. — Blachez, Danger des bains froids chez 
les typhoidiques [Gaz. med., 2 fevrier, 1877]. — Peter, Raynaud, Fereol, Soc. med. des hop, 1876, 1877. — Schultz, 
Ueber die Resultate der Kaltwasserbehandlung de Typhus abdominalis, in Acad. Krankenhause zu Heidel- 
berg [Abhand. der Heilbeib. nat. Med. Vereins: neue serie I, 1 Heft, 10 et 24 fevrier, 1884]. 

(6) Soulier, Typhoid Fever and Cold Baths at Lyons, Paris, 1883, p. 45. 



384 ON THE TREATMENT OF TYPHOID FEVER. 

lutely safe. 1 They allay the excitement of the nervous system, diminish the 
sensation of burning heat, and enable us to maintain perfect cleanliness in our 
patients. 

There are two ways of administering tepid baths. Some, as Ziemssen, 
Schutzenberger, and Laure, of Lyons, employ baths of decreasing temperature, 
and from 95 F. they lower the temperature of the water, in the course of ten 
minutes, to 77° F. 2 Others, and I am of their number, keep the warm bath at 
a constant temperature of five degrees below that of the patient, to wit, varying 
from 93 F. to 98 F. These baths should be of much longer duration than the 
cold baths, and without going as far as Reiss, who keeps the patient in them 
almost all the time, I am of the opinion, relying especially on the experiments of. 
Thery, that it is sufficient to prolong them from twenty to thirty minutes. 3 

1 Curry was among the first to vaunt the action of tepid baths in the treatment of 
typhoid fever. These tepid baths were, moreover, anciently employed by Hippocrates and 
Galen. 

Dance, in 1831, recommended the employment of tepid baths in the treatment of typhoid 
fever. Hervieux in 1848 also devoted a chapter to the utility of these baths in dothinen- 
teritis. Such baths at a constant temperature of 30 to 35 C, (87 to 95 F.) were shown by 
the experiments of Barthe and Berthornier made on themselves, to have caused lowering of the 
pulse from 16 to 20 beats and the temperature one degree. 

Dujardin Beaumetz has noted the same effect in patients affected with typhoid fever 
and has seen the temperature fall two degrees and the pulse ten beats. (a) 

2 Ziemssen employs baths of decreasing temperature. He makes use of water of 33 C. 
(91 F.) of temperature at the commencement, then he adds cold water so that at the end of 
ten minutes the temperature of the bath is not higher than 23 C. (73 F.) These baths are 
administered four times in twenty-four hours, at six and ten o'clock in the morning, and six 
and ten o'clock in the evening. 

Laure, of Lyons, has employed the same methods. The water was first used at an 
initial temperature of 30 C. (86° F.) and was cooled to 25° C. (77 F.) The duration of the 
immersion varies from fifteen to twenty minutes. The patient ought to make some 
voluntary movements while in the bath, or else be rubbed in front and on the back. 

Schutzenberger employs baths of 25 to 30 C. (77 to 87 F.) and lets the temperature 
of the bath cool down (as it naturally would) from two to three degrees during the immer- 
sion, which is from fifteen to twenty minutes in length, (b) 

3 Riess employs permanent tepid baths in the treatment of typhoid fever; he places the 
patient on a hammock and makes him remain for several hours in a bath at a temperature 
of 88° F. 

Afanowjewhas employed the same method; he places his patients in a bath of from 75 ° 
to 85 ° F. on a rubber mattrass, the head resting on an air cushion. The maximum duration 
of the bath is three hours; two baths are given every day. 

Hermann, on the contrary, considers these prolonged tepid baths of no advantage. 



(a) Dance, Sur le traitment de la fievre typhoide (Arch. Gen. demed., ire serie, t. PXV, p. 186). — Her- 
vieux, De l'emploi des bains tiedes et de leur utilite" dans le traitement de la fievre typhoide (Areh. gen. de 
med., 4e serie, t. XVIII, p. 28). — Barthe, Recherches sur l'emploi des bains dans la fievere typhoide dans le 
but d'abaisser la temperature (theses de Montpellier, 1871). — Berthornier, Des bains tiedes et de leur influence 
sur l'abaissementdu pouls et de la temperature (these de Paris, 1874). — Dujardin-Beaumetz, De l'emploi des 
bains tiedes compare a celui des bains froids dans le traitement de la fievre typboide (Soc. med. des hop., 22 
decembre 1876). 

(b) Ziemssen, Die Kaltwasserbehandlung des Typhus abdominalis, Leipzig, 1870.— Laure, De l'emploi 
du bain tiede de preference au bain froid dans le traitment de la fievre typhoide (Soc. des sc. med. de 
Lyon, 1874). 



ON THE TREATMENT OF TYPHOID FEVER. 385 

These baths are repeated once or twice a day, the attendant having care to sustain 
the forces of the patient by giving him, during the bath, wine and meat broths. 4 
I have always seen, under the influence of these tepid baths, typhoid patients 
with hyperpyrexia and delirium manifest a notable amelioration of the symptoms, 
become calm, and obtain quiet sleep. 

I shall say little about the employment of refrigerant apparatus, not 
because I doubt their value — on the contrary, they are the only means which 
enable us to apply, systematically and rigorously, the refrigerant method — but 
because I have had no personal experience with regard to them. They are, 
in fact, quite complicated and costly, and this is why no one but their inventor, 
my colleague, Dumontpallier, has applied them in practice/ If we refer to the 
conclusions which he has recently formulated, these apparatuses have given him 
good results. We find means much more easy of application in cold affusions, 
lotions, and the wet pack, which can be used by anybody. 

Affusions of cold water, or rather of sea- water, which was Currie's treat- 
ment of fevers, are no longer in use, and the cold lotions of which I have 
already spoken are far preferable. 6 These lotions of cold water are decidedly 
antithermic in their action, as no one who has watched their effect can have 

They have no action in typhoid fever, and diminish neither the length nor the gravity of the 
disease, (a) 

4 Thery has studied the influence of prolonged baths on the circulation and calorifica- 
tion. Baths above 97 F. augment the circulation and the temperature; below 97° F. they 
lower them both. From 90 to 97 F. the fall is from four to six-tenths of a degree. This 
heat fall is more tardy with baths at 86° and below. Thermometric depression obtained by 
a bath at 93° F. lasting one hour is equivalent to the fall determined by a bath of thirty 
minutes at 71° F. (b) 

5 These are the conclusions formulated by Dumontpallier : 

1. The refrigerant method in typhoid fever cannot be judged, except by experimental 
and scientific researches. 

2. This method carefully conducted, not exclusive of other treatment, may offer great 
advantages in therapeutics. 

3. It cannot make pretentions to the cure of all patients affected with typhoid fever, 
but in modifying the hyperthermia and its consequences, it may diminish the mortality in a 
notable proportion, (c) 

6 Currie employed affusions of cold or of tepid water. These affusions consisted in 
throwing over the patient a certain quantity of cold water; then he bathed him with vinegar 
and water and afterwards with sea-water. He preferred in general for these affusions, sea- 
water to river-water. He made use also of affusions of tepid water, that is to say, of water 
from 87 to 95 F. 

Wanner employed sponge lotions which he called passes; this sponging was repeated 
several times a day. {d ) 



(a) Riess, Ueber den Einnuss des parmanenten Cauwarraen Bades auf die Temperatur des Typhus 
(Centralbl , No. 30, 1880). — Afanowjew, Ueber die Behanlung von Typhus Krankenmit Langdauernden lauen 
Badern (Saint-Petersbourg Med. Woch., No. 26, 1881.) 

(<5) Thery, Physiological study on prolonged baths. These de Paris, 188 1. 

(c) Dumontpallier, contribution to the study of the refrigeration of the human body in febrile diseases 
and in particular in typhoid fever. [Acad, des sc, Feb. 26, 1883.] 

(d) Currie, Medical Reports of Cold Water, etc., Edinburgh, 1797. 
§25 



386 ON THE TREATMENT OF TYPHOID FEVER. 

failed to observe; the temperature falls appreciably under their use, especially 
if they are repeated several times a day. This heat-reducing power is, I well 
know, limited, and in certain grave cases of ileo-typhus these lotions do not 
suffice to bring down the temperature, and we must have recourse to more 
active means. I believe the refrigerant action of these lotions to be a secondary 
effect, the principal and dominant action being that which they exert on the 
vaso-motor functions of the cutaneous capillary network, functions so pro- 
foundly disturbed in typhoid fever, and which tend to become restored under 
the influence of these cold lavations or spongings. 

This vaso-motor and revulsive action is much more energetic when the 
wet pack is used. 1 The method is very simple; the patient, in a state of 
nudity, is wrapped from head to foot in a sheet or blanket wrung out of ice- 
cold water. It is well, as a preliminary step, to have a rubber blanket spread 
upon a mattress; over this you place the wet sheet, in which you wrap your 
patient. Liebermeister advises that this envelopment should be continued for 
ten minutes; for my part, I prefer a shorter duration of a minute or so, after 
which the patient is taken from the wet sheet and removed to his bed. If I 
prefer wet wrappings of short duration, to the practice of Liebermeister, it is 
because I do not wish to obtain refrigeration from these envelopments, but 
only a regulative modification of the nervous system, and this effect will be the 
more marked, the shorter the duration of the cold application. This is, gentle- 
men, one of our most powerful modes of treatment in cases of typhoid fever of 
ataxic and adynamic character, and you will derive great benefit from it. Foltz 
has recently added co^d lavements to the refrigerant medication. 2 These lave- 

1 Priesnitz, Scoutetten, and Liebermeister have studied the action of wet wrappings in 
fevers. This envelopment is made in two ways; in the one the patient, being naked, is 
wrapped in a blanket wrung out of cold water; the application does not last longer than a 
minute, then the patient is rubbed dry and put into bed, 

Liebermeister employs another method; it consists in leaving the individual wrapped 
in a wet sheet and covered with a woolen blanket for ten minutes, and in renewing this wet 
pack three or four times in succession. 

According to Liebermeister, four successive wet wrappings thus practiced produce the 
same effect as that of a bath at 68° F. lasting ten minutes. Ziemssen and Zimmermann have 
not obtained from this wet pack so notable a refrigerant action; it is true that they do not 
prolong the duration of the wrappings so long, (a) 

2 Foltz, of Lyons, has treated 27 patients by cold lavements, and has administered to 
each of them a number of lavements which has varied between 30 and 300. Out of these 27 
patients only one has succumbed. The quantity of water varies with the age, from eight 
ounces to a quart; the temperature of the water was between 50 and 6o° F. 

Brand has observed that cold lavements lower the temperature from o c .2to o°.5; but 
this fall does not last long. Prosper Boyer, basing himself on the results obtained by Bar- 
rallier, of Toulon, affirms that cold lavements are superior from the point of view of the re- 
frigerant medication, to cold baths, (b) 



(a) Liebermeister, Handbuchder Pathology und Therapie des Fiebers, Leipzig, 1875.— Scoutetten, Rap- 
port sur l'hydrotherapie, adresse a M. le Marechal ministre de la guerre, apres un voyage fait en Allemagne, 
Strasbourg et paris, 1843; De l'eau sur le rapport hygidnique et medical de l'hydrotherapie, Paris, 1843, in-8 ° . 

(b) Boyer, Comparative utility of cold baths and cold lavements in the treatment of typhoid fever. 
(These de Paris, No. 234, 1875.)— Foltz, on cold lavements in the treatment of typhoid fever. [Lyons Medical 
Journal, 1875.] 



ON THE TREATMENT OF TYPHOID FEVER. 



387 



ments of water at 50 F., lower the temperature of patients — in a feeble manner 
it is true — but still appreciably, and this is a fact worthy of being remembered. 
So wherever you have occasion to give enemata to typhoid patients, see to it 
that the water which you use is cold. 

Having finished refrigerants, I pass now, in accordance with the order 
which I adopted in the previous lecture, to bloodletting. 1 

Very much in use in the treatment of fevers at the commencement of this 
century, and before we had precise notions respecting the nature of typhoid 
fever, bloodletting was still practiced at a later date in this disease by Louis and 
Chomel, and especially by Bouillaud, who thought to jugulate the disease by 
applying to it the formula of "bleeding upon bleeding" (coup sur coup). To- 
day the practice of bloodletting, local or general, is completely abandoned; 
and, nevertheless, whenever nature herself proceeds to the letting of blood, 
and when these losses do not exceed certain limits, we see the temperature fall, 
and symptoms of the greatest gravity abate; so that, in a great many cases, 
intestinal hemorrhages are an element of prognosis rather favorable than other- 
wise. The two clinical charts which I here show you, indicate well the anti- 
thermic action of these hemorrhages. 2 It is true that you sometimes purchase 
this amelioration by a long and painful convalescence; however this may be, 

DAYS OF THE DISEASE. 




Fig. 15. 



1 Louis and Chomel recommended moderate bloodletting in typhoid fever. Bouillaud 
practiced bleeding coup sur coup (repeated bleeding), from the first week of the disease, think- 
ing to cut short the disease; after the second week he abandoned bloodletting and gave a 
tonic regime. Forget, although a partisan of bloodletting, only practiced it in certain forms 
of typhoid fever called inflammatory. 

2 In the first curve (fig. 15) we have represented the pyrexial progress in a patient 
twenty-three years old, and vigorous, who on the fourteenth day of the disease was 
taken with a very abundant intestinal hemorrhage (B.) which caused his temperature to fall 
from 41 to 38 C. The first depression during the eleventh and twelfth days corresponds 
to the administration of salicylic acid. 



388 



ON THE TREATMENT OF TYPHOID FEVER. 



we note the fact without venturing to authorize the interference of the physician 
in order to produce artificially, in typhoid patients, loss of blood. 

I now come to the study of medicaments which act on the fever by the 
intermediation of the nervous system, and we shall examine successively the 
treatment of typhoid fever by digitalis; aconite, veratrum viride and sulphate 
of quinine. 

Tt is. Hirtz who, in our country, has defended with the most ardor the 
treatment of this fever with digitalis, a practice already adopted since 1862 by 
Wunderlich. 1 Digitalis is given in the form of infusion, and fifteen to thirty 
grains of the powdered leaves are steeped in a gill of water, all of which is ad- 
ministered daily in divided doses. These doses, continued for three days, 
cause a notable diminution of the pulse and temperature, but despite this 

DAYS OF THE DISEASE. 



^9 "To! m 12 


3 14 J 5 16 17 


40°L 


. nz 






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; t % k 


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irn n 


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f Li u\ 


39V -V -r- 


ED 3 \ q 


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Fig. 16. 



The second curve (fig. 16) corresponds to a case of typhoid fever in a young man 
of nineteen; the tenth day of the disease supervened a very abundant hemorrhage. The 
next morning (A.) the two patients were better, but their convalescence was long and 
painful, marked by very pronounced thermic oscillations. 

1 Wunderlick, in 1862, counseled the use of digitalis in typhoid fever; he recom- 
mended its administration in the form of infusion, advising to steep from fifteen to thirty 
grains of the powdered leaves in six ounces of water, and give the whole daily in divided 
doses. Under its use he asserted that the pulse and temperature went down. 

Fritz was one of the most ardent advocates in this country of the treatment of 
fever by digitalis. In 1869 he reported the results of this medication, which were strongly 
commendatory. His method was as follows: from ten to fifteen grains of digitalis leaves 
was infused in four ounces of water, of which a tablespoonful was given every hour; 
this treatment was continued for three days. 

Bernheim has observed during this treatment a lowering of the temperature down to 
even 96 F. The pulse and temperature fell at the same time. 

Grimshaw employs digitalis in typhoid fever; according to him this medicament 
diminishes neither the duration of the fever nor the temperature; it only diminishes a little 
the frequency of the pulse and augments the force of the heart's contractions. 

German See is opposed to the administration of digitalis in typhoid fever; he thinks 



ON THE TREATMENT OF TYPHOID FEVER. 389 

powerful antithermic effect, which is not denied by any observer, this kind of 
treatment is not much in favor. One fears, with reason, the action of digitalis 
on the heart, which is so often affected, as we have seen, with symptomatic 
myositis, as well as the emeto-cathartic effects which digitalis determines when 
given in such large doses. 

1 shall not take up your time with the treatment by aconite 2 recom- 
mended by Lavasseur and Deshayes, of Rouen, nor with that of veratrum viride 
employed by Hirtz, Vogt, and Liebermeister, 3 their trials not having been since 
repeated; at the same time remarking, apropos of the first of these medicines, 
that if you wish to experiment with aconite you should use the tincture of the 
root and not that of the leaves, the latter having no medicinal virtue, and I pass 
now to the study of a kind of treatment which has numerous partisans at home 
as well as abroad. I refer to the medication of typhoid fever by quinine. 

Broqua, of Mirande, in 1840, communicated to the Academy of Medicine 
the good results which he had obtained in the treatment of typhoid fever with 
large doses of sulphate of quinine, 4 and we have seen successively Chappotain, 

that to lower the temperature it is necessary to employ daily doses of more than 30 grains, 
and that these doses may be the cause of grave accidents, especially when the heart is 
affected with granulo-fatty degeneration. (a) 

2 In 1863 Lavasseur, and in 1873 Deshayes employed tincture of aconite in the Hotel 
Dieu of Rouen in the treatment of typhoid fever. This is the formula which Deshayes 
employs: 

I£ Alcoholic tinct. of aconite gtt. xx. 

Distilled water § iv. 

Tinct. aurant. cort. q. s. 

M. S. A dessert spoonful every two hours. 

He feeds his patients with beef tea or veal broth (a cupful every two hours), (b) 

3 Vogt has given veratrum in large doses in typhoid fever. Liebermeister prescribes 
pills of one-twelfth of a grain of veratrine every hour till nausea and vomiting" follow. 
From four to six pills suffice. This treatment produces considerable prostration, (c) 

4 . Sulphate of quinine was introduced into the therapeutics of typhoid fever by Broqua, 
of Mirande, in 1840. Chappotain, of St. Laurent, applied the method of Broqua at the 
Hotel Dieu, in 1842. Pereira in his theses made known the results of this method. Boucher 
of the Ville Jossy, in his inaugural theses, insists on the utility of employing large doses, 30 
grains at least. Monneret goes farther and proposes to substitute for the miasmatic poison- 
ing of typhoid fever, the toxic action of sulphate of quinine, hence he would give as much as 
75 grains a day to a typhoid patient. Blache and Briquet report the good effects of this 
treatment in the case of children. 

These tentatives were repeated in Germany by Vogt in 1858, by Wachsmutt in 1863, 
particularly by Liebermeister in 1867. The latter has insisted on the doses and the period 
of administering them. He gives from 30 to 45 grains a day in divided doses of seven or 



(a) Wunderlich, Arch, der Heilkunde, 3e Heft, ams. 1869.— Hirtz, Des indications de la digitale dans la 
fievre typhoide (Bull, de then, t. LXXVII, 1869, p. 223).— Grimshaw, On the influence of Digitalis on the 
weath heart of Typhus fever (the Dubl. Journ. of Med. Sc, juin).— Germain See, Clinique de 1'Hotel-Dieu, 
lecon sur le Traitement de la fievre typhoide (France med., 1878 et 1870, et Mouv. m^d., 1874), 

(<5) Deshayes, On the treatment of typhoid fever by aconite. (Gaz. hebd., 1875). 

(c) Liebermeister in Ziemssen's Anthology. — Louis Boiteux, on Typhoid Fever. (Theses de Paris, 
1883, p. 119). 



390 ON THE TREATMENT OF TYPHOID FEVER. 

of St. Laurent, Pereira, Boucher, of Ville Jossy, Blache, Briquet, and Monneret 
boast of the effects of this medication. Monneret went the farthest in this 
direction, for endeavoring to substitute for poisoning by the typhogenous miasm 
the toxic effect of quinine, he was in the habit of administering as much as 
seventy-five grains a day of this medicine. Such bold experiments were some- 
times followed by bad results; therefore this medication was abandoned, at 

eight grains every ten minutes; he begins the administration of these doses about five 
o'clock in the afternoon. He obtains thus a reduction in the pulse and temperature, which 
persists from twelve to eighteen hours; he waits several days before repeating this dose. 
Liebermeister employs indiscriminately cold baths or quinine, but he prefers the latter 
medication. 

Kaulich and Chapetal, of Vienna, employ Liebermeister's method in the typhoid 
fever of children, and they apply concurrently the refrigerant method and sulphate of 
quinine, which they associate in the following way: every day in the first part of the after- 
noon the child is wrapped in a sheet wrung out of cold water, then is given, in one full dose, 
seven and one-half to thirty grains of quinine (the child being supposed to be from four to 
ten years of age). This mode of treatment is repeated every second day in cases of urgency; 
moreover, a careful alimentation is early commenced. 

Lindwurm, of Munich, never exceeds 30 grains a day. Lassau, of Copenhagen, gives 
the same dose all at once from seven o'clock till nine o'clock in the evening. Herardalso em- 
ploys sulphate of quinine, and goes as high as 45 grains a day. 

Germain See uses sulphate of quinine and prefers it to all other antipyretics; basing 
himself on some experiments made with Bochfontaine; he, in fact considers sulphate of 
quinine as a heart tonic; he gives it in one large dose about seven o'clock in the morning. 

Jaccoud also prefers quinine to salicylic acid. He gives the first day 30 grains of 
bromhydrate of quinine; the second day 20 grains and the third day 15 grains. The medica- 
ment is taken in substance in wafers, each containing 7^ grains; the wafers are swallowed 
one after the other, with ten minutes of interval. Jaccoud administers them in the morning 
when he wishes to lower the evening temperature, and in the evening when he wishes to 
lower the morning temperature, and with respect to this administration he regulates himself 
according to the examination of the temperature of the patient. 

Pa wer employes doses much smaller, and never gives more than seven or eight grains 
a day. 

Teisser has shown the danger of sulphate of quinine in large doses. According to him 
it is an hyposthenic medicament which certainly enfeebles the functions of the nervous 
system. 

Laborde, in basing himself upon his experimentation, has shown that the massive 
doses of sulphate of quinine may determine in certain cases of infectious myocarditis grave 
accidents on the part of the heart. Dujardin-Beaumetz has also shown the danger of these 
large doses of sulphate of quinine, (a) 



(a)Broqua (de Mirande), Acad, de med., 1840. — Chappotain de Saint Laurent, Arch, de med., septembre 
1842, t. XV, 3e serie, p. 5. — Pereira, Recherches cliniques sur l'emploidu sulfate de quinine a haute dose dans 
le traitement de la fievre typholde (these de Paris, 1842). — Boucher de la Ville- Jossy, Quelques reflexions sur 
Faction physiologique du sulfate de quinine a haute dose en general, et, en particulier, dans le trakement de la 
fievre typholde (these de Paris, No. 22, 1846). — Monneret, article Fievre Typhoide, Compendium, t. VIII, p. 
258. — Blachez et Briquet, Un m6d., 3 novembre 1853. — Liebermeister, Recherches physiologiques du sulfate 
de quinine sur l'homme sain (Arch. Schm., 5 vol., CXVI, p. 275). — Oeffner, Die Anwendung des chinis bei der 
Behandlung der Typhus, Munich, 1874. — Germain See., Lecons de clinique faites a. l'hopital de la Charite 
(Mouv. med., 1874, e t Acad, de m6d., 1883.) — Oehme, Zur Anwendungsweise des chimins in Typhus abdomin- 
alis (Zeitsch. f. Prak. Med., Nos. 42 et 43, 1875). — Jaccoud, Traitement de la fievre typhoide, lecons a la 
Faculte, 28 et 30 novembre 1881, et Acad, de med., 1883. — Dujardin-Beaumetz, Acad, de med., 1882 et 1883.— 
Laborde, voir Jules Simon, Des succ^danes en therapeutique (these de Paris, 1882).— Pawer, Large doses of 
quinine in enteric fever (the Med. Times and Gaz., ier fevrier 1873). — Kaulish, Therapeutische Beobachtungen 
heim Typhus abdominalis (Jahrbr. f. Kenderh., Bd. XVII, Heft 1, seYie ire, 1881). 



ON THE TREATMENT OF TYPHOID FEVER. 391 

least in our country. Vogt, in 1858, and Wachsmuth, in 1863, and, lastly, 
Liebermeister, in 1867, repeated these first tr'als, but this time they applied to 
the study of the effects of the medicament the use of the thermometer, and gave 
precise indications of the administration of the medicine. This treatment was 
rapidly adopted in foreign lands and in France, and we see Lindwurm, of 
Munich, GEffner, Larsen, of Copenhagen, Pawer, Kaulich, Jaccoud, Germain 
See, Herard, Barthez, and others, put in practice this medication. 

It is the sulphate of quinine that is most often employed; yet in Germany 
use is made of the hydrochlorate, and in France Jaccoud prescribes the bibrom- 
hydrate of quinine. These salts are administered in solution, or oftener in 
capsules; the pill form should be discarded, for it not seldom happens that on 
account of the state of the digestive tube, these pills pass through the intestinal 
canal unaltered. But the capital point, and it is this on which Liebermeister 
has insisted, is to give large doses; for example, you should make your patient 
take eight grains every fifteen minutes till half a drachm has been reached. 
Liebermeister often exceeds this quantity, and continues giving the small doses 
every quarter of an hour till from forty to sixty grains are administered, but in 
this country we generally stop at half a drachm. 

The period of administration of these massive doses has also a 
great importance. Liebermeister counsels to give the quinine between 
five and seven o'clock in the evening ; Germain See prefers the morn- 
ing ; Jaccoud, with good reason, says that you should give it in the morn- 
ing or evening, according to the effect which you desire to obtain. Do 
you wish, for instance, to procure a lowering of the evening temperature? give 
your quinine in the morning; Do you wish to obtain a matinal fall? give it in 
the evening. Liebermeister and Kaulxh give one large full dose on one day 
only, and do not repeat the dose unless the temperature takes on again an 
ascending march. Jaccoud gives his salt of quinine in decreasing doses 
for three days. See administers it without interruption. I believe that the 
method by interruption has great advantages over the continuous employ of the 
medicament, and you ought to be guided in this regard by the thermometric 
curve. 

Employed after this fashion, sulphate of quinine produces in typhoid 
patients a very pronounced depression of the pulse and temperature, which 
lasts often for two days, and when the thermal curve rises it does not attain as 
high a point as before the exhibition of the quinine. But this antipyretic action, 
obtained with such large doses of quinine, has certain advantages. In giving 
to the patient thirty, and often forty or more grains of quinine, you are likely 
to overstep the therapeutic effect, and obtain the toxic action on the brain 
and on the heart. Germain See and Bochefontaine affirm that this cardiac 
action is of a tonic kind, but Laborde, with much reason, maintains that it 
is dangerous in hearts with degenerated muscular fibre, and you know that 
the latter is a very common complication in the infectious diseases. 1 More 

1 Germain See and Bochefontaine have noticed by experiments on animals and by 
direct tracings on the healthy man and in the febricitant, that sulphate of quinine supports 
the heart's force and even augments it; it especially causes disappearance of the dicrotism 



392 ON THE TREATMENT OF TYPHOID FEVER. 

over (and this is an argument which I adduced in the last discussion at the 
Academy), the typhoid patient is a bad subject for treatment, not only because 
absorption of medicines is difficult in consequence of the unhealthy state of the 
digestive tube and the lymphatic vessels, which originate there, but also because 
the functions of the kidney and the liver are notably compromised. In a 
former course of lectures I showed you the capital importance of the liver and 
of the kidney from the point of view of the action of medicines, and from all 
these considerations you see how easy it is, when drugging your typhoid 
patients, to exceed the therapeutic and obtain the toxic action of your remedial 
agents. 

You ought always, gentlemen, to have these facts in mind when prescrib- 
ing active medicines in large doses to your patients in this fever. And while 
recognizing the benefits of quinine medication, I believe that it is best to be 
very prudent in the administration of this alkaloid, and never to exceed the 
dose of thirty grains a day, and always to have care not to give this medicament 
continuously. Therefore, I much prefer, as an antipyretic, salicylic acid to 
quinine, because one obtains antithermic effects quite as powerful with the for- 
mer, and in doses which entail less danger. 

It was Riess who first, in 1875, applied salicylic acid to the treatment of 
typhoid fever; and since this first trial, Schroeder, Nathan, Fischer, Ewald, 
Goldtammer, Bselz, in foreign lands, and in France, Garcin, Noel Gueneau de 
Mussy, Jaccoud, Oulmont, Haliopeau, Caussidon, and Rabeau, and, especially* 
Prof. Vulpian, have shown us the advantages which may be derived from sali- 
cylic acid in this disease. Salicylate of soda, salicylate of bismuth, and salicylic 
acid have severally been employed. 2 Salicylate of soda is preferred by the 

which results, according to them, from direct diminution of the blood pressure, and more- 
over from relaxation of the walls of the vessels due to intensity of the fever. 

Laborde, on the contrary, while recognizing the action of quinine on the heart shows 
that in animals massive doses determine ataxia of the heart; an ataxia which leads to the 
complete exhaustion and cessation of the efficacious contractions of the heart, (a) 

2 Buss was the first, in 1874, to employ, at the Cantonal hospital of Saint Gall, salicylic 
acid in the treatment of typhoid fever. He gave it in powder, in the wafer form, or in emul" 
sion in water. He declares that salicylic acid given in doses double that of quinine, has the 
same antipyretic efficacy as the latter. 

The year following, in 1875, Riess treated 250 cases of typhoid fever by salicylic acid. 
He gave from 75 to 100 grains of salicylic acid a day, and he administered it in solution with 
bicarbonate of soda. He observed by this means a notable diminution in the pulse and 
temperature. 

Schroeder has also employed salicylic acid, or rather its solution, in alkaline menstrua, 
and prefers the salicylate medication to the cold bath treatment. Nathan, of Kiel, in 1875 
recommended much larger doses, giving as much as 180 grains of salicylate of soda a day. 
Fischer prefers salicylic acid, which he administers in substance in wafer form. He gives 
massive doses of from 30 to 120 grains morning and evening. 

Liebermeister has also employed salicylic acid; he prefers the salicylate of soda, and 
remarks that its antipyretic effect is more noticeable than that of quinine. Ewald also pre- 
fers salicylate of soda. According to him the minimum dose necessary to lower the temper- 



(a) Germain-See et Bochefontaine, Comp. rend, del' Acad, des sc, 1883, et Gaz. med. de Paris, 3 feVrier 
1883, p. 52.— Laborde; voir Jules Simon, Des succedands en therapeutique (these de Paris, 1883, p. 39). 



ON THE TREATMENT OF TYPHOID FEVER. 393 

greater part of German physicians, as producing less irritation of the alimentary 
canal than salicylic acid, and as being quite as good an antipyretic. I do not 
hold this opinion, and believe with Prof. Vulpian, supported as is this belief by 
numerous cases occurring in my hospital practice, that salicylic acid possesses 
— in equal dose — an antifebrile action far superior to that of salicylate of soda; 
and I am as much a partisan of salicylic acid in the treatment of this fever as I 
am of»the salicylates when it is a question of rheumatic fever. Salicylate of 
bismuth, which I was the first, I believe, to employ in therapeutics (not, indeed, 
in typhoid fever, but to combat the fetid diarrhoea of infancy), has been utilized 
by Vulpian m the treatment of dothinenteritis. Guided by the idea — very just, 

ature should be 75 grains. Riegel, of Cologne, also gives the acid dissolved in water by 
means of the salts of soda; he pretends thus to avoid the irritation of the digestive tube. 
Goldtammer vaunts the effects of salicylic acid, he also prefers the salicylate; small doses at 
intervals, according to him, produce no effect, but a massive dose of 75 grains given in the 
evening determines a fall in the temperature of more than three degrees, 

Baelz gives from 60 to go grains of salicylate of soda once or twice a day; he has ob- 
served under this treatment a fall of 6°, and even 6°. 5 without any concomitant dangerous 
phenomenon; he has also noted that the temperature when it goes up again, attains a less 
height than before the administration of the salicylate. He has not noted any degree of ex- 
citation till after doses of 60 grains; this excitation is more intense in women than in men. 
He has also observed an augmentation in the quantity of urine and the appearance in the 
latter of salicylic acid eight minutes after the administration of this medicament in a patient 
affected with exstrophy of the bladder. Albert Robin has, on the contrary, noticed a dimin- 
ution of the quantity of urine, and a very marked augmentation in its density, which may 
attain 1044 under the influence of 90 to 120 grains of salicylic acid. 

In France the employ of salicylic acid in typhoid fever dates from 1875. At this 
epoch, Garcin, of Marseilles, administered salicylic acid in the dose of seven to 15 grains, 
this is the same dose that Noel Gueneau de Mussy gives; the latter employs from 15 to 30 
grains of salicylic acid, dissolved in one or two ounces of gum arabic water, sweetened with 
syrup; from one to four teaspoonfuls of brandy are added. 

In 1876 Jaccoud also made trial of salicylic acid; he made use of capsules containing 
eight grains of salicylic acid and gave 30 grains the first day, 20 the second, 15 the third; he 
now prefers sulphate of quinine to salicylic acid. 

Hallopeau employs, in their order, salicylate of soda, sulphate of quinine and calomel; 
this is how he proceeds in his medication: the first day of their entry the patients take 15 
grains, or a scruple of calomel; the days following he gives them either salicylate of soda in one 
dose only of 30 grains, or sulphate of quinine in the dose of 15 or 20 grains; then he contin- 
ues alternately these two medicaments, having care not to leave his patients subjected more 
than three consecutive days to the action of the salicylates. He prescribes simultaneously 
cold lotions renewed from three to five times a day, cold applications over the abdomen and 
cold lavements. In the ataxic forms, he has recourse to digitalis simultaneously with cold 
baths; the visceral congestions are combatted besides by repeated applications of dry cups. 
He endeavors to sustain, as far as possible, the forces of the patient by making him take 
every two hours a cup of milk or of broth; the typhic patients thus ingest regularly four or 
five quarts of milk a day. Apart from the calomel given the first day, M. Hallopeau makes 
little use of purgatives, which have the inconvenience of hindering the administration of the 
antipyretics, and whose utility appears problematical in a disease where diarrhoea is almost 
constant. 

Vulpian is a great advocate of the employ of salicylic acid, which he prefers to the sali- 
cylate of soda, and the results of his practice have been published in the thesis of Henri 
Rabeau. He administers the salicylic acid in the quantity of 75 to 100 grains a day, in pow- 
ders oi 1% grains an hour. The defervescence produced by this medicament follows a con- 



394 ON THE TREATMENT OF TYPHOID FEVER. 

indeed — that typhogenous virus develops especially in the last portion of the 
small intestine, Vulpian thought of this medicament, which seemed to him 
likely to reach without any alteration the diseased places in the intestine, and 
there combat, in situ, the development of the infectious organisms. But the 
results have not met his expectations; salicylate of bismuth has, indeed, lowered 
the temperature, but it has had no influence on the march of the disease. So, 
despite the more satisfying results which Desplats has obtained, this medica- 
tion has not found much favor. 5 

Salicylic acid should be administered in capsules, and in a dose not exceed- 
ing sixty grains, for more than this determines, especially in females, cerebral 
excitation, buzzings in the ears, and gastro-intestinal irritation. I, moreover, am 
always careful to give at the same time a little milk to mitigate the symptoms 
of the latter, and when I come to speak more particularly of the details of man- 
agement of this fever, I shall tell you the rules which I follow in giving salicy- 

tinued progression and the evening exacerbations are less marked, so that in 24 or 36 hours 
the temperature falls to 98^ and even lower. 

But this medicament has no action on the pulse. With defervescence there is pro- 
duced an amelioration of all the general symptoms. At the same time the salicylic medica- 
tion has no influence on the march of the disease; it does not diminish its duration or pre- 
vent relapses. Such are the principal results of Vulpian's observations. 

Caussidon, of Algiers, considers salicylate of soda as the best antithermic agent to em- 
ploy in typhoid fever; he gives 15 grains every two hours till the temperature falls to 
ioo° F. (a) 

3 Salicylate of bismuth presents itself under the form of a pulverulent body of little 
solubility. The salicylate which is found in commerce always contains a certain quantity of 
free salicylic acid, and which varies according to the mode of fabrication. Jaillet has pro- 
posed the following process: 

After having prepared a quantity of crystallized acid nitrate of bismuth, this salt is pre- 
cipitated in 500 times its weight of water, rendered feebly alkaline by caustic soda, and con- 
taining in solution a proportion of salicylate of soda double that of the nitrate of bismuth 
employed. 

After the deposition of the precipitate, you decant the supernatant liquid, and add 
a new quantity of pure water, and when the precipitate has been washed three times, to re- 






(«) Buss, Ueber die Anwendung der Salicylsaeure als Antipyreticum (Deutsch. Arch, fur Klin. Med , 
1875; zur Antipyretischen Bedeutung des Salicylsaeure, Stuttgard, 1876). — Riess, Ueber die innerliche Anwen- 
dung des Salicylsaeure (Berl. Klin. Woch., 1875, P- 181 et 194). — Schroeder, Zur Anwendung des Salicylsaeure, 
resp. des natron Salicylicum (Deutsches Arch, fur Klin. Med., 1876, Bd. XVIII, p. 514).— Nathan, Ueber die 
Bedeutung des natron Salicylicum als Antipyreticum (Diss, inaug., Kiel, 1875) —Fischer, Zur Antipyretischen 
Werkung des Salicylsaeure und des Salicylsauren natrons (Deutsch. Zeitsch. fur Prakt. Med., 1875). — Lieber- 
meister, Handbuch der Pathologie and Therapie des Fiebers, p. 644.— Typhus abdominalis (Ziemssen's Hand- 
buch der Specullen Path, und Therapie, Bd. II, 1874^. — Antipyretische Medicamente (Ziemssen's Handbuch 
der Allgemeinen therapie, 1880, Bd. I, p. 69). — Ewald, On Salicylic Acid as an Antipyretic (the Pract., 1876). — 
Riegel, Ueber die innerliche Anwendung des Salicylsaeure (Berl. Klin. Woch., 1875, p. 673 et 699). — Goltdam- 
mer, Zur inneren Anwendung der Salicylsaeure (Berl. Klin. Woch., 1876).- — Baelz, Salicylsaeure, Salicylsaeures 
Natron und thymol in irhem Einnus auf Krankheiten (Arch, der Heilk., 1877;.— Alb. Robin, Note sur l'acide 
salicylique dans la fievre typeoide (Gaz. Med. de Paris, 1877). — Garcin, Onze cas de fievre typholde traites par 
l'acide salicylique (Journ. de ther. , 1876). — Jaccoud, Traitement de la fievre typholde (Mouv. med , 1877, p. 164 
et 181, et lecons sur le Traitement de la fievre typholde, 28 et 30 novembre 1882), — Hallopeau, Traitement de la 
fievre typholde par le calomel, le salicylate de soude et le sulfate de quinine (Un. med , 1881, et Soc. med des 
h6p., 13 aout 1880). — Vulpian, Traitement de la fievre typholde par l'acide salicylique (Bull. Acad, de m^d., 22 
aout 1882). — Caussidon, Traitement de la fievre typhoide par le salicylate de soude (Gaz. hebd., 1881, p. 283). — 
H. Rabeau, Etude sur la medication salicylee dans la fievre typholde (these de Paris, i883\ 



ON THE TREATMENT OF TYPHOID FEVER. 395 

lie acid. In doses of from half a drachm to a drachm it lowers the temperature 
two or three degrees without much influencing the pulse. By not exceeding 
this quantity of the medicament, I have never observed any cardiac or nervous 
symptoms to follow. It is not so with the next antipyretic of which I shall 
speak, viz: carbolic acid. 

Desplats, of Lille, 4 was the first to found the phenic medication of typhoid 
fever; the trials made previously by Pecholier, Tempesti, and Skinner were 
not successful, by reason of the small doses given. Desplats gives phenic 
acid in lavements containing twenty to thirty grains, and gives three or four of 
these a day; these lavements should be retained so that the medicament may 
be absorbed. Phenic acid has a considerable antipyretic action, and for my 

move every trace of salicylate, the product is collected and dried rapidly in a stove heated 
to 104 F. 

The substance which is thus obtained is quite crystalline, and constitutes the acid sali- 
cylate of bismuth, and has the following formula: 

(Bi203) (C14H604) 5-fl6HO. 

After having prepared, by the method just given, the acid salicylate of bismuth, if you 
continue washing the precipitate till the decanted water no longer gives a violent reaction 
with perchloride of iron, you obtain a new salicylate of bismuth, which this time represents 
by its composition the sub-salicylate or basic salicylate of bismuth, which has for formula: 

Bi2 03, C14H604 X2Bi2 03, C14HS04. 

It is then a mixture of two basic salts. Ragoucy has disputed the correctness of these 
formulas. 

One of these salicylates, the acid salicylate, contains more than 50 per cent, of oxide of 
bismuth, and 40 per cent, of salicylic acid. The other, the alkaline, contains more than 76 
per cent, of oxide and 23 per cent, of salicylic acid. 

The absolutely different proportion of these two compounds ought to give to these two 
preparations different therapeutic properties. 

Vulpian has made use of the commercial salicylate of bismuth containing from 30 to 45 
grains of salicylic acid to every three drachms of the salicylate. 

Vulpian administers three drachms of the salicylate every 24 hours, dividing this quan- 
tity into fractional doses to be given at intervals of an hour or an hour and a half; he has 
thus obtained a notable lowering of the temperature of from one to three degrees; the stools 
are disinfected and scanty. In fine, this medicament has had no influence on the march of 
the disease. 

Desplats administers from 75 to 100 grains of salicylate of bismuth in fractional doses 
of 15 to 30 grains; he has in certain cases observed a veritable abortive action, and the 
typhoid fever has been arrested in its course, (a) 

4 Declat was one of the first to employ phenic acid in typhoid fever; but his observa- 
tions, having no scientific character, have not been taken into consideration. Stephen Skin- 
ner, in 1873; Pecholier, in 1874; and Tempesti, in 1877, have also employed this acid, but 
in such small doses that its therapeutic effect cannot be appreciated. It was Desplats (de 
Lille) who first, in 1880, gave the proper rules for the administration of this medicament, and 
his method has since been adopted by his pupils, Van Oye and Maquart, and by Clodo, at 



(a) Jaillet, Des salicylates de bismuth (Bull, de ther., t. CV, 15 aout 1883, p. 113).— Ragoucy, Sur la com- 
position du salicylate de bismuth (Bull, de ther., t. CV, isoctobre 1883, p. 328).— Vulpian, Sur desessais de traite- 
ment de la fievre typholde au moyen du salicylate de bismuth (Journ. de pharm., 1882). — Rabeau, De la medi- 
cation salicylee dans la fievre typholde (these de Paris, 1882, p. 55). — Henri Desplats, Application du salicylate 
de bismuth au traitement de la fievre typholde (Soc. de ther., 23 mai 1883, et Journ. des sc. med. de Lille, 1883). 



396 ON THE TREATMENT OF TYPHOID FEVER. 

part I have seen doses of less than half a drachm administered in lavements, 
produce a fall in the fever of nearly five degrees. Such an antipyretic action is 
not, however, produced without danger; it is, in fact, accompanied with pro- 
fuse sweats, pallor of the integument, and often an alarming state of collapse. 

Last year (in 1882), I often had recourse to carbolic lavements, and fre- 
quently observed pulmonary congestions in patients thus treated; in calling to 
mind the toxic effects noted in animals poisoned by phenic acid, where these 
pulmonary congestions are the rule, I attributed to my medication a certain 
part in the production of these thoracic complications, and discontinued the 

Lyons, by Vulpian, Bouchard, Siredey, etc., in Paris. Desplats employs the following 
method: He makes use of lavements containing from 8 to 15 grains of phenic acid dissolved 
in a little less than four ounces of water. 

These lavements are renewed every three hours, so that from a drachm and a half to 
two drachms of phenic acid are administered daily; the lavement is given by means of a 
syringe, and a soft rubber tube carries the liquid high up in the rectum, so that the lavement 
is sure to be absorbed and retained. 

When the patients can take the carbolic acid by mouth, Desplats employs the follow- 
ing lemonade: 

Phenic Acid, 2 to 4 grammes, 

Lemonade [lemon juice and water] , 100 " 

Simple Syrup, 100 " 150 " 

He gives the patient about 100 grammes (about three tablespoonfuls) every three hours, 
each dose containing about ten grains of phenic acid. This medication is not employed ex- 
cept when the temperature attains or exceeds 104 F. 

Claudo employs two lavements a day; one at 8:00 o'clock a. m., and the other at 4:00 
o'clock p. m., containing from 15 to 24 grains of phenic acid dissolved in five ounces of 
water at 63° F. Vulpian made use of phenate of soda, giving as much as 30 grains in lave- 
ments. 

The dangers of this method were well shown at the time of the discussion which took 
place before the Societe des Hopitaux, in 1882. 

Dreyfus Brissac, Dujardin-Beaumetz and Siredey pointed out the collapse and the 
pulmonary congestions which accompany the administration of phenic acid, and Siredey has 
also cited the toxic action of this acid. 

Similar facts were given in 1881 at the Biological Society, by Raymond. 

In 1881, Glenard considered phenic acid as producing toxic accidents, and that its 
application to typhoid fever does not lower the rate of mortality. Ramonet also pointed out 
that among the accidents laid to the charge of the phenic medication, pulmonary congestion 
is the most frequent and the most formidable. 

Desplats has responded to these various objections in replying that phenic acid properly 
administered does not produce any of these accidents. At the same time he admits that the 
administration of this acid is not without danger, (a) 



{a) Stephen Skinner, On the Treatment of enteric Fever by use of internal Disinfection (the Pract., Sep- 
tember 1873). — Tempesti, Usage de l'acide phenique dans la fievre typholde (lo Sperim., Janvier 1877). — Pecho- 
lier, Sur les indications du traitment de la fievre typholde par la creosote ou l'acide phenique et les affusions 
froides (Montpellier med., juillet 1874, p. 36). — Desplats, Sur 1'emploi de l'acide phenique comme agent antipy- 
retique (Acad, de med., 1880). De l'acide phenique applique au traitement de la fievre (Journ. des sc. m6d. de 
Lille, 1881). Action comparee de l'acide phenique et du salicylate de soude (.Journ. des sc. med. de Lille, 1882). 
Traitement de la fievre typholde par l'acide phenique (Bull, de ther., t CIII, 1882, p. 193). — Van Oye, De Tac- 
tion de l'acide phenique sur les febricitants (thes de Paris. 1881).— Maquart, Traitement de la fievre typholde 
par l'acide phenique (these de Lille, 1882). — Glenard, Valeur antipyretique de l'acide phenique dans le traite- 
ment de la fievre typholde, acide phenique ou bains froids (Lyon med., 1881). — Ramonet, De Taction et des 
regies de la medication phdniquee dans la fievre typholde (Arch. gen. de m^d., 1782). — Siredey, Vulpian et 
Bouchard; voir Royer, De l'acide phenique et du phenate de soude (these de Paris, 1881, et Soc. des hop., 1882). 



ON THE TREATMENT OF TYPHOID FEVER. 397 

employ of these phenic lavements. Since then, at the Medical Society of the 
Hospitals, at the time of the discussion which followed the report of Ferrand 
on the method of Desplats, several of our colleagues, and in particular Siredey 
and Dreyfus Brissac, mentioned similar facts; therefore, gentlemen, while 
recognizing the powerful antipyretic action of phenic acid, this medication 
must be considered as dangerous, and when you have recourse to it you cannot 
exercise too great care and watchfulness. For my part, I think it should be 
abandoned altogether. 

Resorcin has been little used in typhoid fever. You will see, when I come 
to speak of intermittent fever, that it has been used to advantage in this fever, 
but although I have made many attempts to introduce this substance into the 
therapeutics of our country, I have not obtained any very positive effects from 
it in ileo-typhus. As for kairine, I am not aware of any definite results which 
have been obtained from it in this disease. 

I pass now to the study of germicide medication. You already well know 
that a great number of antiseptic medicaments have become, by their thera- 
peutic application, antipyretic medicaments; this is what has happened in the 
case of many substances derived from the aromatic series. It remains for me 
now to speak of medicaments which, while possessing an evident antiseptic 
action, have not, at the same time, any effect on the temperature. 

It is thus that there have been successively applied to the treatment of 
typhoid fever, creasote by Pecholier 1 and Morache, iodine and the iodides by 
Aran, Magonty, and Wilbrand; 2 a combination of iodine and carbolic acid by 
Roberts Bartholow and James C. Wilson; chlorine and the hypochlorites by 

1 Pecholier, of Montpellier, employs an antizymotic treatment in typhoid fever. This 
treatment consists in the use of creasote in the dose of 3 to 5 drops, associated with the 
essence of lemon. He employs also cold affusions, but only to combat the ataxo-adynamic 
element. 

Morache also employed creasote at Val de Grace, in 1870. He gave from 4 to 8 drops 
a day. The stools were disinfected, and a thermic depression was noticed. Out of 59 
patients affected with typhoid fever, where this method was applied, there were 59 
deaths, (a) 

2 Sauer proposed, in 1840, to treat typhoid fever with iodide of potassium. Aran, in 
1853, employed, in typhoid cases, tincture of iodine, administering daily from 13 to 30 drops. 

Magonty, in 1859, an d von Wilbrand, in 1866, employed in the treatment of typhoid 
fever, the iodureted solution of iodine. This solution has the following formula: 

Iodide og. 30 — ( 5 grains). 

Iodine of potassium 2.00 — ( 30 grains). 

Water 10.00 — (150 grains). 

Dose, 3 or 4 drops every two hours, in a wine-glass of water. 

Liebermeister, who has tried this medication, has observed no result, but the mortality 
was less in patients where this iodo-iodureted solution was employed, {b) 



(a) Pecholier, on the indications of the treatment of typhoid fever by creasote, or phenic acid, or by 
cold affusions. — (Montpellier med., July, 1874, p. 36) Morache, on the employment of creasote in typhoid 
fever. — Gaz. (des hop., 1871, p. 394.) 

(<S) Aran, on the employment of iodine in typhoid fever (Bulde ih.6r., 1853). Magonty, new treatment 
of typhoid fever (Paris, 1859). Liebermeister, in Ziemssen's Cyclop. Art, typhoid fever. 



398 ON THE TREATMENT OF TYPHOID FEVER. 

Chomel and Beaufort; 3 the sulphites and hyposulphites by Polli; 4 prepara- 
tions of copper by Burq and Moricourt; 5 mercurial preparations (the black 
sulphuret) by Serres; and calomel by Wunderlich 6 and Liebermeister, also by 
Bartholow and Wilson in America. I shall not dwell further on these antiseptic 
preparations, this medication not being established on a scientific basis; for, if 
by the introduction of antiseptic substances it has been possible to disinfect the 
stools, it has been impossible to arrest the course of the disease, that is, to 
prevent the development and penetration of the micro-organisms into the 
entire economy. 

Regis also employed iodine, both by respiration and by deglutition. He was in the 
habit of putting in the mouth of the patient pastilles containing from i to 2 grains of iodine. 
These pastilles were not to be chewed. Every hour he gave the following potion: 

Tinct. iodine og.20 (4 grains). 

Syrup 30.00 ( I j). 

Orange-flower water 20.00 ( 3 v). 

Peppermint water 60.00 (3 ij). 

[In this country Professor Bartholow has used, apparently with decided success, the 
following modification of the iodine treatment: 

^ Tinct. iodinii 8.00 c. c. (fl. 3 ij). 

Acid, carbolic 4.00 c. c. (fl. 3 j.) 

M. Sig. 1 to 3 drops three times a day. 

He now gives it every three hours, during the day and night. (Boston Med. and Surg. 
Journ., Feb. 1, 1883.)] 

3 Chomel has employed, since 1831, the dried hypochlorite of soda, dissolving it in the 
proportion of about 15 grains to a pint of water. He thus gives his patients daily from 30 
grains to a drachm of the salt. He employs, also, lavements containing 15 grains of the 
hypochlorite. He also wets cataplasms with Labarraque's solution and sprinkles the floor 
and the bed-clothes with the same. 

De Beaufort has employed a solution of hydrochloric acid diluted as lemonade, con- 
taining from half a drachm to a drachm of the acid to each quart. 

Winter (of Giessen) has employed chlorine and obtained excellent results from it. 

4 Polli employs in typhoid fever sulphites and the hyphosulphites; this medication, 
according to Murchison, has very doubtful results. 

Wilks employs sulphurous acid [giving two to three drachms a day, well diluted], and 
Meklhausen has obtained success by this same treatment. 

5 Burq has shown, by statistics, that workers in bronze are protected from cholera 
and typhoid fever. Taking a hint from this, Moricourt has prescribed small doses of am- 
monio-sulphate of copper by mouth and by lavements. 

Burq's prophylactic consists in giving binoxide of copper pills (^ gr.), and thinks that 
this preventive treatment is " full of hope." (a) 

6 Serres has proposed the treatment of typhoid fever by mercurials. He makes fric- 
tions with mercurial ointment over the abdomen, rubbing in 2 to 4 drachms of the ointment 
per diem, giving also internally a scruple of the black sulphuret of mercury. Grisolle has 
tried this method, and has found it absolutely inefficacious. 

Calomel seems to have given better results than the black sulphide of mercury. Tauff- 



(a) Burq, on the treatment of cholera by copper (Gaz. des hop., 1883). Maricourt, treatment of typhoid 
fever by cupric preparations (Gaz. des hop., 1882). 



ON THE TREATMENT OF TYPHOID FEVER. 399 

Calomel, which terminates this long series of antiseptic medicine, belongs 
rather to the evacuant than to the parasiticide medication, and will serve as a 
bond of union between the two. The idea which gave rise to the evacuant 
medication was perfectly just, especially at the time when this medication was 
first instituted. In fact, we have seen De Larroque maintain since 1832, 7 that 
it is in the fecal matters that the septic element of the disease is found, and 
that it is necessary, in order to prevent the poisoning of the entire organism, to 
eliminate these septic matters by stool. You have seen that experimental 
physiology has justified this view of the subject; only, in their haste to eliminate 
the peccant principle, the founders of the evacuant method have gone a little 
too far, and have not hesitated to give every day an ounce of castor oil or a 
bottle of Seidlitz water. Carried to this extreme, the purgative method is 
rather injurious than useful; it weakens the patient, and, by exaggerating the 
peristaltic movements of the diseased intestine, it may be the exciting cause of 
haemorrhage or of perforation. Utilized in moderation, however, the evacuant 
method is a serviceable adjuvant to treatment, promoting elimination of pu- 
trescent matters. 

It remains for me to speak of the tonic and empirical medication. The 
tonic medication is now universally popular, and in order to repair the inces- 
sant losses which the organism undergoes from the exaggerated combustions 
which the febrile process determines, preparations of quinine have been em- 
ployed, and, along with suitable alimentation, alcoholic stimulants. 8 

I shall not repeat what I said about alimentation while on the hygienic 
treatment of typhoid fever, nor shall I dwell further on preparations of bark, 

lieb pretends by these medications to have arrested the march of the disease. Wunderlich 
has also noted a diminution in the duration of the affection under calomel. 

Liebermeister has also obtained good results. The latter gives three or four half 
gramme doses of calomel in the course of 24 hours, at the onset of the disease. He 
never noticed stomatitis of any gravity. Liebermeister assures us that the mortality is 
diminished, and the duration abridged by this treatment, (a) 

7 Larroque, who in 1839 and 1844, published elaborate treatises on typhoid fever and 
its treatment, has given the most explicit directions as to the evacuant medication of this 
disease. His faith in the curative benefit of purgatives was based on this idea that the 
septic matters contained in the stools, by remaining in the intestine, effect alterations in that 
viscus and penetrate the organism, poisoning it; and Fremy compared what took place in 
such cases with what happens in suppurating wounds when in free communication with their 
septic products. The treatment was as follows: 

At the commencement, an emeto-cathartic was given, and every morning the patients 
took a little Seltzer water, or an ounce of castor oil, or a half drachm dose of calomel. The 
mortality in these cases was only about ten per cent. Piedagnel (the author of a treatise 
bearing date of 1835), in employing Larroque's method, had a mortality of 14 per cent., and 
Andral, of 16 per cent. 

8 It was Graves, Stokes, and especially Todd, who introduced alcohol into the treat- 
ment of fevers, and typhoid fever in particular. 

Jaccoud administers alcohol in all cases of typhoid fever, prescribing according to the 



(a) Serres, Du traitement de la fievre typhoide paries preparations mercurielles (Acad, des sc, 1847). 
Wunderlich, De la temperature dans les maladies, 1872. — Liebermeister, Typhus abdominali in Ziemssen's 
Handbuchdes Allgemeinen therapie, Bd. II, 1874. 



400 ON THE TREATMENT OF TYPHOID FEVER. 

only pointing out this fact, that the potions containing the soft extract of cin- 
chona, which are so much administered in these cases, often pass through the 
alimentary canal without undergoing any modification; and in many instances 
I have found in the stools of my patients almost the whole of the extract which 
I had given them. But I must devote a little more time to a consideration of 
alcohol. 

Since the works of Todd in England, and those of my master, Behier, in 
France, the use of alcohol in this fever has acquired great vogue, and I have 
already spoken of the advantages and disadvantages of this medication, while 
on the treatment of pneumonia. In typhoid fever, alcohol does not act as an 
antipyretic, and if you wish to lower the temperature by this agent, you will 
have to give such large quantities of it that the treatment will be more dan- 
gerous than useful; but, given in proper doses, alcohol acts as a tonic, and, 
moreover, diminishes that process of denutrition which results from exagger- 
ation of the combustions; this is its great utility. 

To those who adopt the opinions of Lallemand, Perrin, and Duroy, it is 
very difficult to explain this waste-restraining action, because, in their belief, al- 
cohol does not undergo any transformation in the organism. According to the 
hypothesis which I have defended, and which seems to-day experimentally 
demonstrated, this kind of effect is quite readily explicable. I maintain, in 
fact, that alcohol, in presence of oxyhemoglobin, and by virtue of the feeble 

constitution, strength, and habits of the patient, from one to three oz. of rum or of brandy in 
the form of cordial potion, or of julep, adding 30 to 50 grains of extract of cinchona. 

Murchison does not administer alcohol constantly ; he gives with precision the indica- 
tions and contra indications of this medication, which he formulates in the following way : 
It is, he says, advantageous to give spirituous liquors to alcoholic subjects early in the dis- 
ease, and in quantity proportioned to the number of years exceeding forty which the patient 
may have passed. A quick, soft, compressible, irregular, intermittent, wavy pulse calls for 
alcohol, whose good effect is seen in slowing and strengthening the pulsations ; if, on the 
contrary, it accelerates them it does harm. 

Alcoholic stimulants should also be given to patients who perspire profusely, and in 
whom this perspiration does not coincide with amendment of the general symptoms. 

In typhoid subjects with dry, brown tongue, it is always indicated, and it may even 
be given in cases of typhoid fever with delirium, when the delirium is not aggravated under 
its use. Alcohol is also indicated in the adynamic forms, and in those accompanied with com- 
plications. 

It should be abstained from in patients below thirty years of age, in patients with dry 
skin, in cases complicated with delirium, which alcohol is almost sure to augment, especially 
in noisy, acute delirium, in cases where an intense cephalalgia is observed, with injected 
eyes and cerebral determinations, lastly, in patients where the urine is scanty, of little den- 
sity, poor in urea, and rich in albumen. 

Fourrier, in a valuable article on typhoid fever in the Bui. gen. de. Ther. for 1873, 
showed all the advantages to be derived from alcohol in dothinenteritis. According to him, 
alcohol diminishes the duration of the disease, and acts well in cases where delirium exists. 
In 1871 Antellet also insisted on the antipyretic action of alcohol in typhoid fever. He main, 
tained that alcohol diminishes the fever and lowers the temperature, (a) 



(a) Jaccoud on the treatment of typhoid fever. Paris, 1873.— Murchison on typhoid fever. London, 
1878. — Antellet on the antipyretic action of alcohol in typhoid fever. Paris, 1871. 



ON THE TREATMENT OF TYPHOID FEVER. 401 

bond which in this substance unites oxygen to haemoglobin, appropriates the 
oxygen, and, transforming this oxyhemoglobin to reduced haemoglobin, modi- 
fies and arrests in a certain measure the oxidation of the tissues of the economy. 

Todd, Murchison, Fourrier, and Autellet have shown us the good effects of 
the alcoholic medication in typhoid fever. Notwithstanding the advantageous 
results claimed, I do not believe that we ought, following the example of Jac- 
coud, to give alcohol to all our typhoid patients indiscriminately; and I believe 
that it is best to reserve this remedial agent for certain cases which I shall soon 
have occasion to describe. 

By the side of alcohol we should place that triatomic alcohol known under 
the name of glycerine, which Semmola has administered with good effect in 
fevers, 1 and which you may utilize advantageously under the form of glycero- 
tartaric lemonade in your practice. 

I shall have finished this long series of medicaments and medications when 
I have spoken to you of ergot of rye, which is recommended by Duboue. 2 
Basing himself on physiological data, very ingenious but rather hypothetical, 
this authority advances the opinion that the typhoid virus affects particularly 
the muscular contractility, and especially that of the arterioles, and it is this 

1 Semmola counsels the following formula : 

I£ Glycerine 3 j. 

Citric or tartaric acid 3 ss. 

Water Oi. 

M. — Sig. to be used freely as a drink in typhoid fever. 

According to Semmola glycerine is a sparing medicament (aliment d'epargne), which 
is very useful in the treatment of severe febrile processes, especially in typhoid fever. (a) 

2 Duboue believes that the typhoid poison acts especially as a vaso paralytic ; the 
poison induces nutritive troubles of the muscular system, but especially of the vascular 
system, causing diminution of the contractility of the blood vessels. The heart and vessels 
thus altered cease to functionate, and there results a general stasis, with vascular conges- 
tions ; the stasis gives rise to globular alterations, which, in their turn, become toxic agents, 
and determine other congestions. It is thus that he explains the favorable action of ergot of 
rye in the treatment of dothinenteritis, ergot being a vaso-constrictor medicament. 

This writer recommends always to verify the goodness of the ergot before making 
use of it ; the grains should be carefully examined, and if eroded or full of holes, or covered 
with white mould, they should be rejected; the fracture of the grains should be smooth. As 
for the medium dose, it is from 20 to 50 grains for an adult, and from 8 to 15 grains for child- 
ren of from 6 to 12 years of age. 

You should always commence, unless in very severe cases, with a relatively small 
dose; the daily quantity should be administered in fractional doses, every three, four, or six 
hours. The powder may be given in capsules or wafers, each containing from two to six 
grains; in grave cases it is better to administer this powder in the form of potion. 

The effects of ergot medication are very speedy, even in grave cases. 

To avoid relapses and sudden death, Duboue recommends the administration of ergot 
until an advanced period of convalescence, but in feeble doses (eight grains daily in two four- 
grain doses). 

Lardiez, author of a treatise on the use of ergot in typhoid fever, published in 1882, and 



(a) Semmola on the employment of glycerine in acute fevers. Bui. de Ther., 1883, t. civ., p 
§26 



402 ON THE TREATMENT OF TYPHOID FEVER. 

paralysis of the vaso-motors which constitutes the essence of typhoid fever. 
To this want of contractility, he opposes medicaments which have the property 
of augmenting the tone of the bloodvessels, and, in particular, ergot of rye. 
The trials which I have made with this treatment have not given any positive 
results, and I believe that if the spurred rye and its derivations are ever indi- 
cated in this disease, it is to combat the intestinal hemorrhages which so often 
occur. 3 

In this therapeutic arsenal, the richness of which I have already shown 
you, physicians have chosen arms of various kinds, sometimes a single weapon, 
sometimes several, with which to fight abdominal typhus, and have thus consti- 
tuted single medications and complex medications, and, according as they have 
applied them exclusively to all cases of dothinenteritis, or as they have varied 
them according to circumstances, they have made thereof exclusive medications, 
or medications according to the indications. Lastly, another group of physicians 
have thought that by the unaided efforts of nature, typhoid fever ought to end 
in recovery, and have applied to the treatment of this disease the doctrine of 
expectancy. Hence we have these three systems of treatment ; exclusive medi- 
cation, expectancy, and medication according to indications. I cannot too 
much protest against exclusive medication, whether in typhoid fever or in any 
other disease. One patient is never just like another patient, and it is absurd 
to suppose that the practice of medicine can be summed up in a simple 
breviary, containing, • on the one hand the description of the dis- 
ease, and on the other the therapeutic formula that will cure it. 
Age, sex, state of the vital forces, the symptomatic aggregate, above all the 
genius of the epidemic, modify the disease in its totality, and at every step in 
its evolution. 

The science of the physician consists in modifying the treatment according 
to the divers circumstances, and it is from this fact that results that intimate 
union which I regard as so indispensable, of clinical medicine and thera- 
peutics. Do you believe that typhoid fever is the same in an infant as 
in an old person ? Do you believe that grave cases can be assimilable to 

who has employed the method of Duboue, considers ergot of rye as a powerful means of 
medication, and of which he has personally seen the beneficial effects. Guichard also con- 
siders medication by ergot of rye as of marvellous efficacy, (a) 

3 Edwards Duffield has employed in typhoid fever the tincture of dyer's weed (baptisia 
tinctoria), giving it the dose of two or three drops every two hours. This remedial agent, 
which he recommends for the more grave cases, has not been employed by other ob- 
servers, {b) 



(a) Duboue\ La physiologie pathologique de la fievre typholde, Paris, 1878.— Des effets compares des 
divers traitements de la fievre typholde et de ceux produits en particulier par le seigle ergote" de bonne qualite\ 
Paris, 1883.— Du traitement de la fievre typholde par le seigle ergote [Acad, de mdd., 5 et 12 septembre, 1883]. 
— Lardier [de Rambervillers], De l'emploi de l'ergot de seigle et de ses derives dans le traitement de la fievre 
typholde et du controle a exercer sur la bonne qualite de ce medicament [Gaz. hebd. de m£d. et chir., 22 de- 
cembre, 1882, et 5 Janvier, 1883].— Guichard, Concours med., 21 octobre, 1882, p. 520. 

(<5) Edwards Duffield on baptisia tinctoria in typhoid fever. New York Med. Record, Nov. 1, 1872. 
[The baptisia tinctoria has long been a favorite remedy in typhoid fever, as well as in septic putrid fevers 
generally, among the Eclectics of the U.S.] (Tr.) 



ON THE TREATMENT OF TYPHOID FEVER. 403 

light cases ? Do you believe that benign epidemics are suitable for compar- 
ison with malignant epidemics ? Do you believe, in a word, that one same 
therapeutic formula, rigorous and uniform, can be made applicable to all cases 
indiscriminately, and that we can thus reduce to a common level all forms of 
the disease ? 

I know well that the partisans of the exclusive treatment, whether single or 
complex, pretend to reduce all cases of the disease to one and the same type, 
but this is only an assumption which is not supported by the facts, and as 
Professor Vulpian says with so much justice, we have not as yet found a kind of 
treatment which is sure to modify the march of this disease and arrest its 
course. There are physicians who pretend to have methods which jugulate 
typhoid fever; but when we come to examine attentively all the so-called jugu- 
lating medications, we perceive that to obtain all the benefits which they prom- 
ise, they must be applied in the first seven days of the disease, that is to say, in 
a period in which one is almost sure to confound simple gastro-intestinal irrita- 
tion (embarras-gastrique) with typhoid fever. It is these same physicians who 
have called to the support of their doctrine of jugulation, the mild forms of 
typhoid fever described by Jules Guerin, and which the Germans have treated 
under the name of typhus-levissimus, and in which one sees the malady undergo 
its evolution in from twelve to fifteen days; but these are natural forms of the 
disease and not the result of modification by therapeutic means. 

There is no such thing in existence as expectancy, properly so-called, 
applied as a medical or therapeutical system, for physicians who boast of 
employing this method take all due pains, nevertheless, to surround the patient 
with all the hygienic care which his situation demands, and to attend to the 
hygiene of your patient is not to deprive him of therapeutic aid, but to render 
him excellent therapeutic service.. But often these hygienic attentions are 
insufficient, and more active intervention is required, and you must then resort 
secundum artem to the medication according to indications which I have styled 
armed expectancy. This expression, armed expectancy, has given rise to much 
criticism. Germain See has condemned it as "revolutionary." I do not con- 
sider that it has this significance, and if our interference is demanded, it is not 
to effect any violent changes in the economy, but to calm and regulate the 
disorders there going on; it is then rather as conservators than as radical inno- 
vators that we act. 

But, you may ask, what are the rules of this " intervention ? " On what 
manifestations do you depend when you decide on the advisability of more 
active therapeutic endeavors ? These three points should guide you, gentlemen: 
the intensity of the fever, the general state of the patient, the complications 
which arise; and, to set forth with more method these three points, we will in 
imagination take a case of typhoid fever, and follow it through the various 
phases of its evolution. 

Your first care will be, as soon as you suspect typhoid fever, to surround 
your patient with all the hygienic precautions which I have above enumerated; 
you take the temperature twice a day, at precisely eight o'clock in the morning 
and five in the afternoon. Although the rectal temperature is always prefer- 



404 ON THE TREATMENT OF TYPHOID FEVER. 

able to that of the axilla, the latter generally suffices. You watch carefully the 
abdominal functions, and you regulate the bowels by giving mild laxatives, such 
as saline purgatives and the natural mineral waters, which are better than 
castor oil. It will be well to cover the abdomen of your patient with a layer of 
cotton batting, which is kept applied by means of a body bandage. This appli- 
cation immobilizes, in a certain measure, the intestinal mass, and prevents the too 
sudden shocks, which, in the present disordered state of the intestines, may do 
mischief. This wadding is much superior to poultices, which are inconvenient 
by reason of the clammy and uncomfortable moisture which attends them. 
Then I make my patient the subject of serious attention, being ready to act ac- 
cording to the rules I have just mentioned; if the temperature does not exceed 
io2° F. ; if no complication arises, I adhere to the hygienic treatment, and 
those mild laxatives administered every day, and you have many times seen in 
my service that these simple means are quite sufficient for benign forms of the 
disease. 

When the temperature exceeds 102 F., I begin the practice of cold lotions 
(sponging), which I repeat two or three times a day, or even oftener, accord- 
ing to the elevation of the temperature. These means often suffice to keep the 
temperature in the neighborhood of 102 F. But when it exceeds 103 F., and 
marches towards 104° F., then is the time for my intervention of salicylic acid. 
I give at noon, and in the space of an hour, four capsules, each containing 
seven and a half grains of salicylic acid, and I take care to administer during 
the day a certain quantity of milk, namely, about a quart. 

Under the influence of the salicylic acid there is a depression of tempera- 
ture; but to render this, in a manner, permanent, I repeat my dose the next 
day, at the same hour, then I omit the treatment for a day or two, and note the 
height of the thermal curve. If it attains the previous figure, I again give the 
acid for two days, in the same dose; and if the temperature still tends to exceed 
104 F., I double the dose, and then give sixty grains in two hours — in doses of 
seven and a half grains every fifteen minutes; and sometimes I go as high as 
seventy -five grains; but I never prolong beyond two days the action of the 
medicament. Such are the sole means which I employ against the pyrexia. 

In order to judge of the condition of the vital forces, I am guided by the 
assemblage of symptoms and the stage of the pulse. 1 As long as the pulse re- 

1 Melherbe has studied the modifications of pulse in relation to temperature in typhoid 
fever; and draws the following conclusions: 1. In typhoid fever the frequency of the pulse 
is not always proportional to the elevation of the temperature; 2. If the pulse remains of 
little frequency, and the temperature of but slight elevation at the onset of a febrile affection, 
typhoid fever is probable; 3. If the pulse remains between 80 and 90 in the course of typhoid 
fever, although the temperature rises above 104 F., or even 105 F., there is not generally 
reason to pronounce the prognosis to be bad; 4. If, on the other hand, the frequency of the 
pulse augments at the same time that the temperature rises above 104 F or 105 ° F., the 
prognosis is very grave; 5. If the temperature suddenly falls, while the pulse increases in 
frequency, the prognosis is unfavorable; 6. The parallelism between the daily oscillations 
is subject to numerous modifications, (a) 



(a) Malherbe, on the diagnostic and prognostic value of the relations of the pulse and temperature in 
typhoid fever [these de Paris, 1883]. 



ON THE TREATMENT OF TYPHOID FEVER. 405 

mains between So and 90 a minute, I let the patient alone; when it raises above 
90, I give alcohol, either in the form of Todd's mixture, milk punch containing 
brandy, or Spanish or Sicilian wines. 

In the immense majority of cases, when the fever takes on a certain acute- 
ness, there supervenes a nocturnal delirium of mild type; when this delirium 
becomes more active and boisterous, I resort to chloral, which I much prefer in 
these cases to opium and its derivations, which, in fact, have for their physio- 
logical effect to congest the brain; and you well understand that in ileo-typhus, 
in which this congestion is the rule, opiates may do harm. I administer, then, 
hydrate of chloral, in the dose of fifteen to forty-five grains, in a mixture of egg 
and milk sweetened; and I frequently associate bromide with chloral. 

A boisterous delirium often accompanies ataxic phenomena, constituting 
thus what was formerly described under the name of ataxo-adynamic fever. 
When this state is not too intense, and the fever is attended with dryness of the 
skin, I place my patient in a warm bath, which I repeat every day or two. If the 
ataxo-adynamic condition becomes more intense, I have recourse to envelopment 
in the wet sheet, which envelopment I repeat two or three times a day, according 
to the necessity. I add often in these cases to the chloral or the bromide, 
preparations of musk, of which Trousseau made great account, and I give from 
seven and a half to fifteen grains of musk, in pills rather than in potion, the 
latter being very disagreeable to the taste. Such are the therapeutic means 
which I employ in the adynamic and ataxic forms of typhoid fever, and I come 
now to other morbid determinations of the disease. 

The pulmonary complications are the most frequent. They include 
bronchitis, pneumonia, broncho-pneumonia, and sometimes, though very rarely, 
pleurisy. In the treatment of these pulmonary complications, you should 
avoid the application of blisters; the patient, in fact, being in a state of constant 
agitation in his bed, and the functions of the skin being altered, these fly- 
blisters are attended with ulceration, or even gangrene, and may thus become a 
serious evil. You should use, instead, dry cups, which render us great service 
in typhoid fever with pulmonary congestion, and with these cups you may 
cover the whole chest of your patient. You may also give internally a little 
tincture of aconite, which diminishes, though feebly, this congestive tendency. 
It will be well also to have your patients well propped up in their beds, so as to 
prevent those hypostatic congestions which too horizontal a position deter- 
mines. 

I have but little to say about cardiac complications, at least from the point 
of view of treatment. Here we have, unhappily, one of the causes of sudden 
death in typhoid fever, not easily explicable always, whether we suppose, as 
Dieulafoy does, a simple reflex action, whether we attribute the fatality, as does 
Hayem, to symptomatic myositis, or whether we make it depend, according to 
Laveran and Bussard, on cerebral anaemia, or whether it results from these 
last two causes combined, as Huchard maintains. 1 Our therapeutics, in fact, 

1 Four theories have been advanced to explain sudden death in typhoid fever. 
1. Theory of reflex action. — This theory has Dieulafoy for its advocate. According to 
him the syncope is due to a reflex action which has its starting place in the diseased intestine. 



406 ON THE TREATMENT OF TYPHOID FEVER. 

have very little power to prevent such a termination. I agree, at the same 
time, with Huchard, that tonics, general stimulants, and perhaps nitrite of 
amyl, may in these cases render some little service. 

On the part of the digestive tube, there may supervene several complica- 
tions. One of these consists in the appearance of gastric troubles, and I have 
already spoken to you of them while on the subject of diet in this disease; the 
other is an accident much graver and always mortal, namely, perforation of the 
bowels; lastly, the third results from the occurrence of intestinal hemorrhages. 
I have little to say to you from a therapeutic point of view concerning intestinal 
perforations, yet apart from perforations as a determining cause, peritonitis has 
been sometimes observed in typhoid patients. In these cases there is a possi- 
bility of a recovery by a rigorous treatment, which consists in the application of 
ice to the abdomen, and immobilization of the intestinal mass. As for intestinal 
hemorrhages, we have seen that when they are of moderate intensity they are 
often rather beneficial than otherwise; unhappily it often occurs that they are 
too abundant, and we are called on to interfere with applications of ice to the 
abdomen, and the internal administration of perchloride of iron or ergotine. 
For my part I very much prefer ergotine or ergotinine, which I give in hypo- 
dermic injections. I have thus far omitted to say anything about the diarrhoea. 
While recognizing the fact that a typhoid patient ought to have two or three 
movements a day, there are cases when the passages are altogether too fre- 
quent, and exhaust the patient. I advise you in these cases to make use of the 
salicylate of bismuth, in from forty to sixty grains a day. 

The renal complications present a certain gravity in typhoid fever. 
Fothergill even thinks that it is the non-elimination of the products of corn- 



He bases himself on the experiments of Goltz, Bernstein, Jarchanoff, and of Francois 
Franck, who have demonstrated that a shock affecting the intestinal mass determines 
sudden arrest of the heart in animals. 

2. Theory of cerebral ancemia. — This theory has been defended by Laveran, and by 
Bussard, according to whom death supervenes from anaemia of the bulb and secondary 
arrest of the heart. 

3. Theory of myocarditis. — Hayem ha? called attention to the frequency of granular 
degeneration of the cardiac muscle in typhoid fever, and it is in this way that he explains the 
arrest of the heart and sudden death in this disease. 

4. Theory of cerebral anczmia and myocarditis. — Huchard shows that none of the pre- 
ceding theories sufficiently explain the pathogeny of sudden death in typhoid fever. Ac- 
cording to him, two predisposing causes, the alteration of the heart and the anaemia of the 
brain, place the typhoid patient in almost continual imminence of syncope. 

The granular degeneration of the heart muscle, and the consequent enfeeblement give 
rise to anaemia of the cerebrum and bulb, and the latter, already pre-existent and persistent 
in the convalescence of typhoid fever, concurs on its part in promoting syncope and in per- 
manently arresting the heart (a) 



(a)Huchzrd, Critical Study on the Pathogeny of Sudden Death in Typhoid Fever (Un. Med., 1877). 
Hayem, Note on the alterations of the muscles in fever, and particularly in variola (Soc. de biol, 1866), also, 
Relations which exist between sudden death and vascular alterations in typhoid fever (Arch, de phys., 1869, p. 
700], also, Studies on the symptomatic myosites, [Arch, de phys., 1870. Dieulafoy, On Sudden death in typhoid 
fever [these inaug., 1870], etc. 



ON THE TREATMENT OF TYPHOID FEVER. 407 

bustion which is the point of departure of the typhoid state. 1 The kidney, in 
fact, is congested in typhoid fever, and the urine is albuminous. Whether we 
are concerned with an infectious nephritis, as Bouchard thinks, or with a con- 
gestive nephritis, 2 there none the less results a perturbation in the functions 
of the renal organ, and I have already spoken to you of the important part 
which I assign to this perturbation in explaning the toxic action of certain 
medicaments in typhoid patients. It is necessary, then, to favor the functions 
of urination, and you can accomplish this by giving abundant drinks to your 
patient, and one of the best is certainly milk. I share, in this regard, the view 
of Jaccoud, who thinks it a good thing to give to his fever patients one or two 
quarts of milk a day. 

The skin, as you know, may become the seat of mortifications more or less 
deep (bed-sores); these eschars are sometimes of great gravity, extending so 
far as to expose the bones of the pelvis. I have even observed myelitis con- 
secutive to the opening of the vertebral canal in typhoid patients. I have al- 
ready shown. you by what hygienic means you may avert these mortifications of 
the skin, but when despite your care they appear, you will require a special 
dressing for them. The best in my opinion is a solution of chloral. It was in 
a case of gangrenous ulceration of the hip of great extent, in a young typhoid 
female, that I made the first local application of chloral, and the astonishing 
results which I obtained from this outward medication encouraged me to study 
and make known the antiseptic properties of chloral, and this work of mine has 
served as a basis for the local therapeutic employ of chloral, to-day so much 
in vogue. 

You make, with one-per-cent. solutions of chloral, frequently repeated 

1 Fothergill has studied the typhoid state; according to him this state depends on the 
retention of materials of combustion which should have been eliminated, and this takes 
place under two conditions. Either there is an excess of production of these effete organic 
matters within a given time, and under circumstances unfavorable to their elimination, so 
that they accumulate in the blood; or else, under conditions of normal combustion, renal 
degeneration prevents their removal from the organism. He concludes that in typhoid 
fever we should aid the various excretory emunctories, skin, kidneys, intestines, etc., and 
promote elimination, (a) 

2 A renal form of typhoid fever has been described by Gubler, A. Robin and others. 
Hardy in 1878 devoted several chapters to this subject. Legreux and Handt and Renault, 
of Lyons, have also studied the renal lesions of typhoid fever. Bouchard has shown by the 
presence of bacteria in the urine the parasitic nature of this nephritis. 

This nephritis is multiple, parenchymatous and interstitial, and the inflammatory pro- 
cess affects all the elements of the kidney. The symptoms of the renal form are character- 
ized by adynamia, stupor, dryness of the tongue, oedema of the members, lumbar pains and 
cutaneous disorders; the last are especially ecthyma, furuncles, etc. The urine is sangu- 
molent, and contains an abundant grayish retractile albumen, (b) 



(a) Fothergill, On the typhoid condition [Edinb. Med. Jour., Dec. 1379, p. 225 ] 

(b) Gubler, Lecons faites a l'hopital Beaujon sur l'albuminurie, et article Albuminuric [Diet, encycl. 
des sc. med., Paris].— A. Robin, La fievre typhoide. Essais d'urologie clinique [these de Paris. 1877].— 
Legroux et Hanot, Observations d'albuminurie dans la fievre typhoide [Arch. gen. de med.]— Renaut, Arch, 
de phys., Janvier 1881.— Bouchard, Des nephrites infectieuses [Rev. de med., 1881, p. 971].— Petit, Des nephrites 
dothienenteYiques [these de Lyon, 1881].— Didion, De la fievre typhoide a forme renale [these de Paris, 1883]. 



408 ON THE TREATMENT OF TYPHOID FEVER. 

dressings, and you have care especially to introduce into the excavation which 
results from the mortification of the tissues, wadding or lint soaked in this 
solution. 

Apart from these eschars I ought to mention erysipelas of an infectious 
kind, and for that very reason of extraordinary gravity; phlegmons, accidents 
quite common in typhoid fever of a subinflammatory character, deeply hidden 
in the interstices of the tissues, and the possibility of which ought to make you 
examine, with the most scrupulous attention, the painful points of which 
typhoid patients sometimes complain during their convalescence. You well 
understand that these purulent collections should be thoroughly drained and 
treated by antiseptic washings and injections. 

Such are, gentlemen, the principal complications which you will have to 
meet; there are still others of which I shall not speak, for they are exceptional; 
such as gangrene of the limbs, oedema of the glottis resulting from laryngo- 
typhus, suppurative parotitis, but it is very rarely that you will have occasion to 
treat these complications. 

I shall say but little of the convalescence of typhoid fever; remarking at 
the same time that relapses are frequent in this disease, and especially that 
variety of remittent or intermittent fever which accompanies convalescence from 
typhoid fever; a variety which David Borelli has plausibly explained by the 
presence of intestinal ulcerations slow to cicatrize. 1 The entire therapeutics of 
convalescence is summed up in a problem of alimentation, and you should em- 
ploy all your care and skill in directing aright the diet. 

Such is the aggregate of therapeutic means which you ought to employ 
in typhoid fever; in putting them in practice you will succeed in curing the 
great majority of your cases, and without admitting with certain physicians that 
it is possible, by therapeutic means, to cause the mortality of typhoid fever to 
disappear, I am of the opinion that there is no disease in which the success won 
by therapeutics are more numerous. 

It is in following step by step the disease whose evolution he has mastered, 
that the physician by his earnest and thoughtful care and his attention to little 
points, by his energetic intervention when complications appear, may in many 
cases say that he has saved the life of his patient, and to express briefly my 
thought, I might conclude with this phrase, which although a solecism, is the 
truth — "The best treatment of typhoid fever is a good physician." 



1 David Borelli has described, under the name of slow ulcer of typhoid fever, certain 
intestinal ulcerations developed under the influence of this disease, and which take a long 
time to undergo reparation. The presence of these ulcerations determines attacks of remit- 
tent fever, which resemble much what one observes in pyaemia, and which are rebellious to 
quinine. Borelli has been able to prove the existence of these ulcerations by post mortem 
examinations. The treatment consists in the administration of milk or broth, in maintaining 
immobility of the abdomen; it is useful to add now and then a laxative to maintain freedom 
of the bowels, (a) 



(a) David Borelli, on slow ulceration of the intestines in typhoid fever [Ann, Clin. degl. Incur, Anno. 

:8 77 ]. 



ON THE TREATMENT OF TYPHOID FEVER. 409 

APPENDIX. 

THE NEW ANTIPYRETIC ANTIPYRINE. 

Since the foregoing chapter was written a new antipyretic has been brought to the 
knowledge of the profession. In many respects this new febrifuge medicament, to which 
the name antipyrine has been given, seems to be superior to all the other agents of the anti- 
pyretic medication. Numerous monographs concerning it have appeared in the medical 
journals of both continents, and the properties of the new medicine have been discussed 
before numerous medical societies. From the already quite extensive literature of antipyrine 
we select portions of the recent contribution of Dr. Leon Arduin, in the Bulletin General de 
Therapeutique, March 30th, 1885 : 

"The antipyretic medication has from all time interested practitioners, and if it will 
not do to accord to fever all the gravity which was attributed to it once, there are neverthe- 
less cases where it becomes not only a complication, but even a veritable danger, against 
which the physician should direct all his efforts. If we pass in review the principal antipy- 
retics employed down to the present time, such as salicylic acid, salicylate of soda, phenic 
acid, resorcin, in fine those of quite recent discovery, such as kairine, aspidospermine, and 
thallin, one does not fail to see that the inconveniences, and sometimes the dangers attend- 
ing these medicaments, make physicians often hesitate to employ them. Only one remains 
in the first rank. I refer, of course, to sulphate of quinine, whose marvellous action is in- 
contestable. Now, in typhoid fever, is it not a fact that the action of quinine becomes nil, or 
almost so, after a few days ? 

Nevertheless, leaving one side intermittent fever, it is still in dothinenteritis that the 
action of quinine is the most manifest. Besides, sulphate of quinine has certain incon- 
veniences attending its use, such as buzzing in the ears, cephalalgia, vertigo, nausea, etc. 
In a word, despite the incontestable action of sulphate of quinine, we are still looking for a 
good antipyretic medicine, for in a number of febrile diseases it is impossible for us, in the 
present state of therapeutics, to lower with certainty a too elevated temperature, and, at the 
same time, to do this with entire safety to the patient. 

Antipyrine is a derivative of oxymethylquinizine, which is the product of acetacetic 
ether reacting on phenyl hydrazine ; if to this oxymethylquinizine you introduce a new 
methylic group, you have methylated oxymethylquinizine, which Knorr has called dimethyl- 
oxyquinizine, and Felehne, antipyrine. This substance is in the form of grayish-white pow- 
der, slightly bitter to the taste, and slightly soluble in water. 

Our clinical and therapeutical study of this medicine is based on more than fifty cases, 
most of them occurring in the practice of Dr. Huchard. Several facts of a practical nature 
result from these observations. The first, which M. Huchard has made known, is the 
almost elective action of antipyrine in diseases of the lungs, and in the fever of the tuber- 
culous ; for it is seen that with minimum doses of eight grains, and even of four grains, you 
obtain a sure fall of the temperature, and this sometimes by more than 2°. 

Moreover, it suffices to cast a glance over the thermometrical tracings, to see the pro- 
gressive and almost mathematical fall of the temperature with feeble doses. Generally the 
first dose makes the temperature fall from i° to i£°. If you cease the administration of the 
medicament the temperature maintains itself at this point for several hours, and even 
descends several tenths of a degree. If you administer a second dose, the heat falls from ^° 
to i°, and keeps at this level for several hours. It is this remarkable action which has 
caused M. Huchard to say that antipyrine might be considered as a specific, not of tuber- 
culosis, but of tuberculous fever. One cannot too much insist on the effect of small doses, 
in opposition to the practice of the Germans, who employ exaggerated doses of from four to 
five grammes ( 3 j to 3 jss) a day. This point, in fact, is of capital importance, for one of 
the greatest inconveniences of antipyrine is the production of excessive sweats, which often 
prostrate phthisical patients. Under the influence of smaller doses, however, of from four 
to eight grains, this inconvenience is completely obviated ; temperature falls, the dyspnoea 
is calmed, the insomnia disappears. 



410 ON THE TREATMENT OF TYPHOID FEVER. 

Our observations show that antipyrine lowers the temperature in pneumonia in a re- 
markable manner, and that this effect is noticed when small doses are used, contrarily to 
what takes place in typhoid fever, where much larger doses are necessary. 

What is now the action of antipyrine in typhoid fever ? It is always attended with a 
fall of the temperature. Large doses, however — as much as 15 grains three times a day — 
are required. Moreover, the temperature falls much less considerably than in diseases of 
the lungs ; i°, i£°, and the duration of this action is shorter. The pulse diminishes sen- 
sibly in frequency, nevertheless this diminution is not in relation with the fall of the temper- 
ature. 

In fine the quantity of urine seems to augment at the same time that a slight diminution 
of the urea is noted. 

In fact, we may already formulate the following conclusions : The general march of 
the disease is not influenced in a notable manner ; hence it will not do to give antipyrine in 
all cases of typhoid fever, but only in those where the temperature is very high ; therefore we 
should not seek to make typhoid fever cases undergo their evolution without fever, but con- 
tent ourselves with lowering the temperature sufficiently so that the disease may follow the 
natural course, i.e., pursue its evolution like a relatively benign acute disease. 

Antipyrine is well tolerated by infants at the breast. It disturbs neither the appetite 
nor the digestion, does not provoke vomiting, causes little vertigo, and no buzzing in the 
ears or headache. It diminishes the frequency of the pulse, has little or no action on the 
respiration. Although large doses are said to have occasioned vomiting, this evil certainly 
does not attend fractional doses. 

As for the physiological effects of this medicament, it has been found to produce in 
hares and guinea pigs convulsions, both clonic and tonic, with paraplegia or general para- 
lysis ; according to Bouchard, it acts on the medulla oblongata and on the brain. It has 
also a remarkable haemostatic action ; we have seen hemorrhage arrested much more 
rapidly with antipyrine than with ergotine, and even perchloride of iron ; it needs, in fact, 
only from two to four minutes for antipyrine to arrest a hemorrhage which takes seven 
minutes for ergotine to arrest, and thirty minutes for perchloride of iron. 

From the point of view of its action on the circulation, we have always noted a slowing 
in the beatings of the heart. Animals die by paralysis of that organ. As for its effect on 
the blood, according to Prof. Demme, it is a protoplasmic poison. The prominent indica- 
tions for the use of this new remedy are hyperthermia and continuity of the fever. 
What ought we to understand by hyperthermia ! Are we to give this name simply to ex- 
treme temperatures, without any distinction of diseases ? A temperature of 104 F., for 
instance, does this constitute an hyperthermic temperature ? Assuredly not. Hyper- 
thermia is not an abstract formula, which we can measure by an invariable figure, which one 
can define by the degree of the fever simply, with the thermometer in hand. The hyper- 
thermia changes with each disease. What is hyperthermia for acute articular rheumatism is 
not hyperthermia for scarlet fever, and if a temperature of 104 F. is hyperthermia for the 
first it is not for the second. 

Now, it is against these hyperthermic temperatures, and it is against them alone, that 
it is necessary to give antipyretics, and it is not when the fever constitutes simply an element 
of the disease that we must give the medicine, it is only when it becomes a complication and 
a danger. But this is not all ; there remains an important point to elucidate. What is the 
end which the therapeutist has in mind in giving antipyretic medicaments ? Do you mean 
always and constantly to bring back a hyperthermic temperature to the normal ? If this is 
the end you have in view, you will find yourself at each moment astray ; you will make 
nothing but failures. 

What you are to demand of these medicaments is to bring back the temperature to 
where it should be in the normal course of the disease, and in doing so you will have sagely 
acted, since you will have suppressed a complication and a danger. 

The second indication is the continuance of the fever. It is useless to insist on the 
benefit which the patient derives from the natural remissions in the course of fevers, and on 
those which the antipyretic procures. 



ON THE TREATMENT OF TYPHOID FEVER. 411 

Modes of Administration. — These are three in number. I, By hypodermic injection ; 
2, by the rectum ; 3, by the stomach. 

1. The hypodermic method is rejected on account of the pain which these injections 
determine. If this method be resorted to, 15 grains may be dissolved in a syringeful of 
warm water and injected. 

2. Antipyrine may be given in lavements. Make a solution, one part to fifteen, and 
add two tablespoonfuls to a small lavement. You obtain thus effects almost as satisfactory 
as when given by the mouth. 

3. In giving antipyrine by mouth, which is the best mode of administration, you dis- 
solve the medicament in a little sweetened water, flavored with a few drops of essence of 
peppermint or tincture of orange peel. It may conveniently be given in a little wine and 
water. 

The doses are : 7 to 12 grains in phthisis ; 15 to 45 grains in typhoid fever and the 
great pyrexias. It is best never to give more than 15 grains at once, and the doses should 
be at least an hour apart. 

Conclusions (Dr. Henri Huchard) : 

1. In all the febrile diseases the fever is not an indication for the employment of anti- 
thermics. It is the exaggeration of the fever. It is the complication of hyperthermia, 
different with each disease, which constitutes the indication. 

2. In the great pyrexias, such such as typhoid fever; in the consumptive diseases, such 
as pulmonary phthisis, the continuity of the fever constitutes anew indication. 

3. In fine, it is necessary to give fractional and feeble doses, to avoid the sweats and 
to avoid plunging the patient into that state of adynamia which may result from abuse of the 
medicament. 

4. In the last place, it will not do to demand of the medication more than it can physio- 
logically perform. I mean to say that it will not do to try to make a grave disease pursue its 
course with a normal temperature. 

Translator. 



ON THE TREATMENT OF INTERMITTENT FEVER. 

Summary: — The Marsh Poison — Its Nature — Atmospheric Influences — Cinchona Fevers — 
Cinchona Bark — Alkaloids of Cinchona — Quinine — Cinchonine — Cinchonidine — Quini- 
dine — Quinoidine — Quinoleine — Physiological, Toxic, and Therapeutic Action of these 
Different Alkaloids — Superiority of Quinine — Absorption and Elimination of the Salts 
of Quinine — Sulphate Chlorhydrate, Tartrate, Bromhydrate, Salicylate, and Tannate 
of Quinine — Mode of Administration — Pills — Potions — Gastric Method — Intestinal 
Method— Lavements — Dermic and Hypodermic Methods — Pomades of Quinine — Pul- 
monary Method — Intra-tracheal Injection of Quinine — Mode of Introduction — Modes of 
Administration — English Method — Italian Method — French Method — Doses — Massive 
Doses — Fractional Doses — Duration of Medication by Quinine — Contra Indications of 
the Employ of Quinine — Influence of Pregnancy — Succedanea of the Salts of Quinine 
— Alkaloids by way of Synthesis — Quinolein — Aromatic Series — Salicylic Acid — Re- 
sorcine — Kairine — Cedron and Valdivine — Picric Acid and the Picrates — Arsenic — 
Animal Substances — Spider Web — Hygienic Treatment — Hydrotherapy — Thermal 
Treatment — Treatment of Pernicious Intermittent Fevers — Treatment of Paludal 
Cachexia — Conclusions : 

Gentlemen: — You know that in marshy localities there prevails a fever of 
an epidemic kind, which is described under the name of intermittent fever, 
fever and ague, marsh fever and malarial fever. It is to the treatment of this 
fever that I shall call your attention to-day. 

What is the materies morbi of this paludal intoxication? This is an etiologi- 
cal consideration of considerable importance, and concerning which we have 
not yet obtained positive knowledge. 

We find two opinions which are prevalent: according to one theory there 
exists a miasm which is in the cause of the disease; according to the other, 
atmospheric influences alone may engender it. With regard to the first theory, 
there exist two hypotheses; that of a telluric miasm, and that of a marsh miasm. 
The first has had for its principal defender, Leon Colin, who holds that all or- 
ganic substances contained in the soil, may, when they are brought in contact 
with the air, by upheavals of the soil, determine intermittent fevers, and thus 
constitute the telluric miasm. Much more numerous are the partisans of the 
doctrine of marsh miasm. 

Relying on experiments on animals, the supporters of this doctrine have 
maintained that stagnant waters are the origin of the marsh poison. Some have 
even localized the toxic principle; Salisbury, for instance, considers certain low 
vegetable organisms of the palmella genus as competent to occasion by their 
introduction into the econonxy, the symptoms of intermittent fever, while Klebs 
and Tommasi-Crudeli have attributed the same effects to micro-organisms of 
the genus bacillus. Bouchardat, moreover, arraigns the infusoria which abound 
in stagnant waters, as being the originators of a virus which may thus poison 
the economy. 1 

1 Vitruve and Varon claimed that the insalubrity of certain countries depends on the 
introduction of minute insects into the economy. Lancisi and Rusoki attributed malaria to 

412 



ON THE TREATMENT OF INTERMITTENT FEVER. 413 

To this theory of the toxic action of ferments, or virus, Eisenmann, 
Burdel, Durand and Munro have opposed another doctrine which, repu- 
diating the idea of telluric or paludal miasm, affirms that all the disorders of 

certain febrigenous animalcules, called by the Italians cerafici. From this came the usage of 
filtering the breathing air through certain respiratory apparatuses worn by patients, or mod- 
ifying this air with garlic from the supposed antiseptic properties of the latter. 

J. Lemaire has also studied the influence of the animalcules, and vibriones, which are 
found in abundance about the marshes. These bodies act, according to Gautier, as a fer- 
ment, and are the cause of intermittent fever. 

Klebs and Tommasi-Crudeli have studied experimentally the pathogeny of intermittent 
fevers by injecting under the skin of hares the products of culture of microbes from the wa- 
ter, soil, and air of countries ravaged by malaria. These experiments have shown that the 
germs of malaria impregnate in great abundance and on a large scale the soil where the 
malady prevails, and even the air in strata which are in contact with the soil. Stagnant 
waters do not seem to hold the germs in suspension. 

When you introduce under the skin of a hare liquids holding in suspension either par- 
ticles from the infected soil, or products of culture, you determine in this animal intermittent 
febrile phenomena; the filtration of the liquids prevents these accidents. In all cases of this 
kind where artificial malarial fever has been induced, tumefactions of the spleen are found at 
the autopsy. 

The micro-organisms belong to the genus bacillus; they constitute mobile brilliant 
spores, and when cultivated develop in the form of elongated filaments, which undergo seg- 
mentation. They are not aerobic, that is to say, they have no need of oxygen for their devel- 
opment; it is in the spleen and the marrow of bones that their micro-organisms develop 
most actively. 

Salisbury has noted on the surface of the soil of certain marshy regions of Ohio, certain 
organized cells, resembling an alga, of the genus palmella. 

These spores are met with in the atmosphere, but only in the night time, and rise only 
to a certain altitude above the soil, viz: from 35 to 100 feet. Salisbury has detected these 
same spores in the expectoration and in the urine of patients affected with intermittent 
fever. 

He has placed earth containing these palmellae in the night time in the windows of the 
sleeping rooms of various persons, and has seen these individuals contract malarial fever. 

Fever and ague has also been attributed to certain microscopic vegetals found on the 
surface of the water in the marshes of Dombes and of Pontines; these microphytes are dif- 
ferent from palmellae. Salisbury gave the name of gemiasma (miasm of the earth) to the 
organisms which he discovered, He describes them thus: 

" Plants having the appearance of cells, consisting of a thin exterior wall, containing a 
nucleus full of minute spores, simple or aggregated; the colors of these plants are varied, 
they are red, green, and yellow." 

Bouchardat also believes that the marsh miasm is produced by a vital act of infusoria, 
which pullulate in the mud of marshes that are in the process of drying; he compares the 
effects of this miasm to those determined by animal poisons. Therefore, the most probable 
hypothesis, according to him, as to the nature of the marsh effluvium, is that it is a poison 
produced by one of the species of microscopic animalcules resulting from fermentation of 
the marshes. Bouchardat, moreover, does not specify the variety of animalcule which 
causes the disease in question. 

Laveran attributes impaludism to certain organisms which he has found in the blood. 
Richards has also detected in the blood the same organisms having a pigmented appear- 
ance, (a) 



(a) Salisbury, On the cause of intermittent and remittent fevers, with investigations which tend to prove 
that these affections are caused by certain species of palmellae (Amer. Journ. of Med. Sc, vol. LI, jan. 1866. 



414 ON THE TREATMENT OF INTERMITTENT FEVER. 

intermittent fever are the product of modifications of the atmosphere, and in 
particular, of atmospheric electricity. 2 To which of these hypotheses shall we 
give the preference? Undoubtedly the influence which the labors of Pasteur 
have had on the study of fermentations, makes the balance incline toward the 
miasmatic doctrine of paludal fevers. Nevertheless I am ready to adopt, with 
Arnould, a mixed theory, which, while assigning a preponderant role to miasms, 
attributes also a certain part to meteorological influences. 3 

Although we cannot determine just what the veritable nature of the marsh 
miasm is, we know, nevertheless, by clinical experimentation, that all the symp- 
toms which result from it are amenable to one and the same treatment, viz: 
treatment by cinchona and its derivatives; hence the name of cinchona fever, 
by which intermittent fever is sometimes designated. But in this application of 

2 Eisenmann puts forth the hypothesis that augmentation and change in the kind of 
atmospheric electricity is the cause of intermittent fevers; he considers the marshes as pre- 
senting circumstances favorable to the production of these electric modifications. 

Burdel adopts the theory of electric influence, attributing the fever to sudden abstraction 
of electricity. He has noted by means of a particular apparatus — the hydro-thermo electric 
condenser — that the production of ozone and of electricity attains its minimum at the middle 
of the day, and it is at this moment that persons generally contract the fever. Durand, of 
Lunel, also admits this electrical influence; according to him the presence of the marsh mi- 
asm in the circulatory passages has for its effect to neutralize or depress the electric state of 
the blood. 

Munroe believes that there is no especial poison associated with malarial fevers, and 
that the action of heat upon fermentations suffices to determine the electrical states which 
induce a more or less intense paralysis of the ganglionic nervous system, and that this 
paralysis is the occasion of all the febrile accidents, (a) 

3 Arnold has divided into three groups the present views respecting the etiology of 
marsh miasm: I. Doctrine of miasm which comprehends that of impaludism and that of 
telluric miasm; 2. Doctrine of meterological elements in which the idea of miasm is rejected, 
and in which meterological elements alone are regarded as the cause of the malarial poison- 
ing; 

3. Mixed doctrine in which are admitted both the influence of miasmatic elements and 
that of meterological elements. (3) 



p. 51-75). — Lemaire, Acad, des sc, 1864, p. 426-317.— Gautier, Etude sur les fermentations (these de Paris, 1869). 
— Klebs et Tommassi-Crudeli, Einige Saetze iiber die Ursachen der Malaria. Studien iiber die Usache des 
Wechselfieber und die natur der Malaria (Arch. f. Exper. Path, und Pharm., Bd. XI, Heft 1 et 2, p. 122, et Heft 
5 et 6, p. 311, 1877). — Bouchardat, Des poisons et des venins (Ann. de ther., 1856, p. 299, et Bull de ther., 15 
d6c. 1883. — Laveran, des Parasites de l'irnpaludisme (Soc. med. des hop., 28 avril 1882). — Richard, Acad, des 
sc, 1883. [Some of the older observers believed the malarial poison to be a gaseous emanation from decom- 
posing- vegetable organisms(C02, H2C and CS2). This view is now abandoned, as refuted by the facts. Others 
have attributed it to the gaseous effluvia from a volcanic soil, others to a modification of the electricity of 
the earth or air. None of these views have been established on sufficient proof, and even the supposed micro- 
scopic vegetable organisms of low grade, the spores and algae, with regard to the influence of which in produc- 
ing malaria, so much has been said, lack as yet all practical confirmation, — Trans.] See Hertz, in Ziemssen's 
Cyclopaedia, Vol. II. page 585. 

{a) Eisenmann; voir Hirsch, Recherches sur l'etiologie de la fievreintermittente (Zeitsch. fur die Gesamm. 
Med., 1849, et Gaz. med., 1850, p. 821).— Burdel, Recherches sur la fievre palud^enne, Paris, 1858, p. 88. — Du- 
rand (de Lunel), Traitement dogmatique et pratique des fievres intermittentes, Paris, 1852. — Munro, Remarks 
npon Malarious Fevers and Cholera, etc. (Arm. Med. Rep., Feb. 1882, p, 263, London, 1874). 

{b) Arnould, on climatal affections and the climatic element in malarial fevers. Arch, gen de Med., 
April and May, 1874. 



ON THE TREATMENT OF INTERMITTENT FEVER. 415 

cinchona bark to fever and ague, it is empiricism alone which has guided the 
physician, and which guides him to-day. Since first the Indians of the village 
of Malacatos gave cinchona in intermittent fever, 1 (centuries ago); since the 
time when the wife of the Viceroy of Peru, the Countess del Cinchon brought 
to Spain this precious medicament, or when, at a later date, the Jesuit fathers 
spread the knowledge of it all over Europe; and since the time, finally, when 
Louis XIV bought of Talbot the formula of this anti-febrile remedy, the ques- 
tion of the anti-periodic effects of Peruvian bark has made little progress 
towards solution. Despite the persevering researches of chemistry which have 
made known the principal alkaloids of cinchona, and despite much careful phy- 

1 It is only since the middle of the 17th century that cinchona bark has been known as 
a therapeutical agent. It is probable that for a long time the Peruvian Indians were ac- 
quainted with the properties of cinchona. But it was not till about 15 years after the con- 
quest, that the Europeans learned the benefit of this medicament, which Geoffry calls 
" God's gift," and which Held qualifies with the attribute of " Divine; " which Morton styled 
as the " Herculean " antidote; and Redi, a miraculous medicine; and which Sydenham 
called admirable. 

According to Jussieu, who was sent to America in 1735 to study the natural history of 
the country, it was the Indians of the village of Malacatos, several leagues to the south of 
Loxa, who were the first to discover the properties of cinchona. He is the author of the 
following note in a work published in Latin in 1739, as cited by Le Maout: 

" It is certain that those who were the first to know the virtue and efficacy of this tree 
were the Indians of the village of Malacatos. These poor people were subject to intermittent 
fevers, caused by the moist heat of their climate, and by the variability of the temperature, 
and they had necessarily to look for a remedy against this sorry malady. As, moreover, 
during the time when the Incas reigned the Indians were versed in the knowledge of plants 
and skilled in discovering their virtues, the experiments which they make with divers vege- 
tal productions led them to find in the bark of Kina-Kina, the supreme and almost sole spe- 
cific of intermittent fever. This tree was designated by them by a name derived from its 
properties; they called it yara choucchou, cava-choucchou; yara signifies tree; cava signifies 
bark; and choucchou means a chill, cold, the horripilation of the fever; it is as if one had 
said, ' the tree of fevers,' 'the bark of fevers; ' they called it also. Ayaca cava; that is to say, 
'bitter bark.' By a happy accident there came, on a brief visit to the village of Malacatos, 
a Jesuit priest afflicted with intermittent fever; the Indian chief, Cacique, having been in- 
formed of the sickness of the ' reverend father ' said: 'Give me a chance, and I will cure 
him.' The priest having assented to the proposal, the Indian ran to the mountain and ob- 
tained the aforesaid bark, and gave a decoction to the Jesuit; the latter, happily rid of his 
fever and restored to health, inquired for the remedy which the Indian had given him. He 
was made acquainted with the bark and obtained a great quantity of it, and returning to his 
country he proved by further trials that it produced the same effects as in Peru. The fame 
of it spread abroad, and the name of Jesuit's powder was given to it, and it was by this 
that it was first known in Europe. 

According to a popular tradition, the wife of the Viceroy of Peru, the Countess del 
Cinchon, had been cured of an obstinate attack of fever and ague by a government officer of 
Loxa, who administered to her some cinchona. On her return to Spain, in 1640, the Coun- 
tess and her physician, Jean Lopez de Vega, brought with them a supply of the precious 
bark and divulged the remedy which took the name of ' Countess' powder.' Later, in 1670, 
the Jesuit fathers sent home, from Peru, some samples of this bark which was consigned to 
the Cardinal de Luco, at Rome, and the remedy took the name of 'Jesuit's Powder,' ' Pow- 
der of the Cardinal,' ' Peruvian Bark,' and ' Febrifuge Bark.' 

Immediately the new remedy was received with favor and enthusiasm, but barks of 



416 ON THE TREATMENT OF INTERMITTENT FEVER. 

siological experimentation to ascertain the modus operandi of these preparations 
of bark, we are still in the dark respecting this subject. Experimental physi- 
ology has in fact in the last few years given origin to a great number of works 
on the action of cinchona, and particularly on that of quinine, and to the primal 
researches of Magendie, of Giacomini, of Desiderio, of Melier, and Briquet, 
it has added a considerable number of treatises whose results are unfortunately 
contradictory. 2 Let us, for example, examine the conclusions which these 
writers have furnished respecting the action of cinchona and its alkaloids upon 
the circulatory and nervous system. 

Some authorities affirm with Briquet, Giacomini, Chirone, Laborde, that 
under the influence of quinine there is a diminution of the arterial blood press- 
ure, while on the contrary Desiderio, Germain See, and Bochefontaine maintain 
that arterial pressure is augmented and that consequently quinine is a tonic of 
the heart. 3 We find the same contradictions with reference to the nervous sys- 

bad quality having been furnished, by merchants little scrupulous as to what they were sell- 
ing, a good many disappointments resulted, and the medicament fell into disrepute. A vio- 
lent opposition was raised on the part of certain physicians of the time; Guy Patin, Chifnet, 
Plempius, Ramazzini, Baglivi, etc., declared it to be useless and worse than useless. But 
the cure of Louis XIV, in 1679, by Talbot's remedy again called attention to this bark. The 
king bought this remedy, which was nothing but a concentrated vinous tincture of cinchona, 
caused it to be made the subject of new trials, which were published by Paul de Blegny in 
1682. Then all were loud in i'-.s praises. Lafontaine composed a poem in its favor; physi- 
cians experimented anew and with more care, and the works of Sydenham, Raclo, Morton, 
Torti, Lancisi, Werlhoff, etc., all agree in affirming the therapeutic value of the precious bark. 
Down to the year 1820, the powder of cinchona, or the decoction of the bark alone was 
used. But Pelletier and Caventou, at this epoch discovered the alkaloids of cinchona and 
these were henceforth put into exclusive use. 

2 Experimental researches on cinchona and its alkaloids date from Magendie, who at 
the time of the discovery of quinine, injected this alkaloid in the jugular veins of several dogs. 
He pretended that quinine was without toxic action and innocuous in animals. 

Giacomini, of Padua, showed on the contrary, in a series of experiments made on 
hares, that sulphate of quinine has very grave toxic effects when administered in large doses, 
and he noted among the toxic phenomena a considerable depression in the functions of 
the circulatory system; he concludes that this alkaloid is a cardio- vascular depressant. 

Desiderio, of Venice, repeated the experiments of Giacomini, and maintained, on the 
contrary, that quinine was a hypersthenisant medicament (an augmenter of tone). Landri, Bal- 
ardini, Leidi and Bergoni, who in their turn made experiments with this salt, advanced the 
same opinion as Giacomini. Melier, in France, repeated these experiments and proved the 
toxic action of this medicament. Finally, in 1853, Briquet published a large work on cin- 
chona and its alkaloids, and maintained that these preparations are agents which attack and 
annihilate the nervous power, wherever it exists; hence he considers quinine as a hyposthe- 
nisant medicament of the nervous system. Since then very numerous works have appeared 
on the subject of the action of the salts of cinchona; it cannot, however be said that the 
views held are yet altogether harmonious, (a) 

3 Experiments made on human beings and on animals to ascertain the action of sulphate 
of quinine on the circulation, have given opposite results. Some experiments affirm that the 



(a) Magendie, Journ. de pharm., t. VII, p. 138. — Giacomini, Giorn. Anal, di Med., 1840. — D^sid^rio, 
Compt. rend, de l'Acad. dessc. octobre 1829.— Melier, Bull, de l'Acad. de mdd., p. 727. — Briquet, Traite thera- 
peutique du quinquina et de ses preparations, Paris, 1853. 



ON THE TREATMENT OF INTERMITTENT FEVER. 417 

tern; 4 according to some, quinine abolishes the sensibility and motrocity; ac- 
cording to others, it is an excitant of these functions. There is the same want 
of agreement moreover in explaining the quinine intoxication, and while Ham- 
mond sees here the effects of cerebral hyperemia, Gubler regards it as resulting 
from ischsemia of the brain. 

How explain such contradictions? Are we to believe that experimental 
physiology applied to the study of therapeutics can give only false and decep- 
tive results? Must we accuse the experimenters of want of skill? Must we 
impeach the reliability of our instrumental apparatus? By no means, and all 

beatings of the heart and the arterial pressure are diminished, others that they are aug- 
mented. 

Giacomini considers this diminution of pressure as a characteristic; hence he places 
quinine among the hyposthenisants (enfeeblers) of the cardio-vascular system, and this opinion 
is shared by the majority of the Italian physicians. 

Vincenzo Chirone has recently repeated these experiments, and this, according to him, 
is the action of quinine on the heart and on the blood-vessels. The systole of the heart is 
enfeebled and the ventricles are distended under quinine; it is the same with regard to the 
blood-vessels — vascular dilatation always resulting. This double action on the heart and 
blood-vessels pertains directly to the muscular fibre and without the intermediation of the 
vascular system. 

In France, Briquet had also noted the diminution of the arterial pressure. According 
to him, this diminution is proportional to the quantity of quinine injected, and, moreover, 
this action is the more intense the larger the doses that are employed. 

In a series of experiments he has shown that this depressant action on the blood-press- 
ure is prolonged for twenty-four hours after the introduction of the medicament into the 
economy. Finally, in other experiments he has demonstrated that the contractile force of 
the heart gradually goes on diminishing and even is ultimately arrested when sulphate of 
quinine is injected into the veins. Laborde admits also a special action of sulphate of qui- 
nine on the heart. This medicament produces a veritable ataxia of that organ. 

In opposition to these views we should cite the experiments of See and Bochefontaine, 
who have accepted the doctrine of Desiderio and of Gubler, who assert that quinine augments 
the contraction of the heart and is a cardio-vascular hypersthenisant (heart tonic). In ex- 
perimenting on men and on animals, they have demonstrated that there is augmentation of 
the blood-pressure and a strengthening of systolic action; quinine is, according to them, a 
tonic of the heart and blood-vessels. 

These differences of estimating the physiological and toxic effects of this drug are owing 
probably to the doses administered, and Jerusalimski has put this fact in clear light by show- 
ing in some recent experiments, that in small and medium sized doses, of from i to 22 
grains, quinine produces acceleration of the pulse and of the blood-pressure, while in larger 
doses it produces, on the contrary, a very considerable fall in the blood-pressure, as well as 
diminution of the pulse. 

It is perhaps necessary also, in order to explain these variances, to make some account 
of the kind of animals which were the subjects of experimentation. In fact Schetschepotjew, 
in studying the action of quinine on the muscles, shows that this action is different in verte- 
brates and in the frog; in man and in the dog quinine augments the force of the contractions 
and accelerates them; in the frog it slows them. 

In order to explain this action on the heart, whether tonic or depressant, two opinions 
have been put forth: Briquet, Leweski, Joiyet, have maintained that quinine acts directly 
on the muscular fibre of the heart and blood-vessels. Chirone has even affirmed that this 
effect on the muscular fibre is a direct relaxant action, and he has generalized this influence 
to all the muscular fibres of organic life, the uterus being included. 

Others, on the contrary, have maintained that it is by the intermediation of the nervous 
§27 



418 ON THE TREATMENT OF INTERMITTENT FEVER. 

these contradictions may be explained by this fact to which I have already called 
your attention while treating of the tonics of the heart, viz: that the therapeutic 
action of the medicament is often the opposite of its toxic action. 

Have we not seen digitalis, that marvelous tonic of the heart, become a 
cardiac poison when it is given in large doses? It is the same with quinine, ac- 
cording as it is administered in therapeutic dose or in toxic dose. In moderate 
doses it tones up the circulation, in large doses it enfeebles it; in moderate 

system that this action on the heart and blood is effected, the medicament being either a de- 
pressant or excitant of the functions of this system. 

Gubler has advanced the opinion that quinine produces its action by galvanizing the 
great sympathetic. 

Schroff, who has always noted a diminution in vascular tension, considers it as result- 
ing from a diminution in the reflex excitability of the vaso-motors. This diminution does 
not result from a modification in the extra cerebral centres of inhibition, Chaperon thinks, 
but rather from a diminution of the excitability of the medulla oblongata and spinal cord, (a) 

4 According to Laborde, quinine acts especially on the cerebrum, but what chiefly char- 
acterizes its action is the absence of convulsions, which readily follow the ingestion of the 
other alkaloids of cinchona. 

Briquet has maintained that quinine causes abolition of the functions of the motor and 
sensory nervous system. 

Dupuis has insisted on the action of quinine on the peripheral sensibility. According to 
him, quinine almost completely abolishes the general sensibility. This abolition is due to a 
direct influence on the sensory centres. The nerve does not lose its property of conducti- 
bility.(^) 

According to Chirone and Curci, this effect is not produced except by toxic doses; in 
therapeutic doses, quinine determines in man only a moderate diminution of tactile sensibil- 
ity. In animals to which large doses of quinine have been given, sensibility disappears in 
the following order: first, tactile sensibility, then algesic sensibility, and lastly thermic sen- 
sibility; the anterior parts of the body are first affected, then the posterior. 

To explain the quinine intoxication, which is a constant symptom in men and in ani- 
mals under the influence of sulphate of quinine, two contradictory opinions have been ad- 
vanced. Gubler maintains that this condition is characterized by a veritable cerebral anae- 
mia, demonstrated, according to him, by the antagonism between opium and quinine. 

According to Hammond, however, the quinine cerebropathy is due to hyperaemia of 
the brain. 

As for the supposed antagonism between quinine and morphia, it does not exist; there 
is, however, according to Pantelejeff, an antagonism between quinine and atropine, the one 
congesting, the other anaemiating the brain. 



(a) Briquet, Traite" therapeutique du quinquina et de ses preparations, Paris, 1853, p. 58, 61, 63.— Laborde; 
voir th. Jules Simon, les Succddanes en therapeutique, Paris, 1883, p. 39. — G. S6e et Bochefontaine, Action 
physiologique du sulfate de quinine sur l'appareil circulatoire chez l'homme et chez les animaux (Acad, des sc, 
fevrier 1883!.— Jerusalimski, Uber bie Ppysiologische Wirkung des Chinin, Berlin, 1875.— Schtschepotjew. Selb- 
standige Contraction der Herzspitze, Veranderunged der Muskeln und der weissen Blutkorperchen unter dem 
Einfiuss von Chinin [Arch. f. die Gesammte Phys., t. XIX, p. 53!.— Le"on Colin, Sur Taction des sels de quinine 
[Bull, de ther., 1872, t. LXXXIII].— Chirone, Meccanismo di Azione della Chinina sul sistema circolatorio e 
Azione sulla fibra musculare in generale [lo Sper., fasc. 10 et, octrobre et novembre 1875].— Gubler, Comm. de 
theV.— Schroff, Beitrage zur Kenntnlss der Chininwirkung [Strieker's Jahrb., p. 175]. 

(5) Dupuis, Etude expeVimentale sur Taction physiologique de la quinine [these de Paris, 1877].— Chirone 
et Curici, Azone della Chinina sensibilita e sul potere lossico [la Scuol. Med. Mapol., ann. II, fasc. 4, 6, 7, avril, 
juin, et juillet 1880].— Gubler, Comm. de th dr.— Hammond, the Influence of the bisulphate of quinine over the 
intra-cranial circulation [New York Phys. and Med.-Leg. Journ., octobre 1874, p. 230].— Panteleieff, Das Salza- 
ure und das Schwefelsaure [Centralb. f. a. Med. Wissensch., n° 29, 1880]. 



ON THE TREATMENT OF INTERMITTENT FEVER. 419 

doses it excites the nervous system, in large doses it depresses it. Unfortu- 
nately experimental physiology can generally study only the toxic action of 
medicaments, and hence becomes rather experimental toxicology than experi- 
mental therapeutics. 

Moreover, this experimental therapeutics in operating on different animals 
may furnish different results, and Schtschepotjew* has well shown that this is 
the effect of quinine, opposite results being obtained according as one experi- 
ments on frogs, hares, dogs or human beings. 

Ignorant, then, of the marsh miasm, ignorant of the principal points per- 
taining to the therapeutic action of cinchona and its derivatives, we are reduced 
to hypotheses to explain the anti-periodic effects, so evident and so indisputable 
of these medicaments, and authorities have by turns invoked in explanation (i) 
a local action on certain organs, (2) an influence on the nervous system, (3) an 
influence oh the blood: 

The theory of a local action of the cinchona alkaloids, as advanced to ex- 
plain their effect on the morbid periodicity, has had few supporters. It is 
necessary, first of all, to assume that the periodicity characteristic of this fever 
results from the hypertrophy of the spleen, which influences more or less di- 
rectly the ganglia of the coeliac plexus, and through that the entire nervous 
system; quinine, by diminishing the volume of the spleen, removes the cause of 
the intermittency. 

Two opinions, directly opposite, have been advanced in support of the 
doctrine which attributes to the effects of the salts of quinine on the nervous 
system their anti-periodic action. 1 The one is defended by Briquet, according 
to which quinine, a veritable kind of "anaesthetic easily managed," as he says, 
annihilates the functions of the nervous system and thereby prevents recurrence 
of the attack; the other supported by Pidoux, asserts that the alkaloids of cin- 
chona act as a tonic of the nervous system, preventing it from becoming en- 
feebled under the baneful influence of the marsh miasm. 

Struck by the antiseptic properties of the salts of quinine, which Pringle 
was one of the first to point out, and which Binz and his followers, and more 
recently Baxter have positively demonstrated, 2 the view has been entertained 

1 Briquet considers quinine as a sort of readily manageable anaesthetic, which by its 
stupefying and hyposthenisant (tone-lowering) action, prevents the nervous fibre from feel- 
ing the morbid influence of the marsh miasm, and in this way opposes the paroxysms of 
intermittent fever. 

Barthez and Pidoux, on the other hand, base the anti-periodic effect of cinchona and 
its derivatives on the force which it gives to the nervous system. The marsh miasm lessens 
the resistance of the nervous system; quinine acting as a tonic of the nervous system, re- 
establishes the stability of the nervous functions, (a) 

2 In 1750, John Pringle remarked the antiseptic action of the alkaloids of cinchona. 
Baxter has repeated the experiments of Pringle, and also those of Binz and his 

pupils. 

Binz had demonstrated that a neutral solution of sulphate of quinine (two-per-cent.) 



* Schtschepotjew, Arch. f. die Gesammete Phys., p. 53. 

(a) Briquet, Therapeutical Treatise on Cinchona and its Preparations, p. 271, 1853. — Pidoux, Therapeutics 
and Materia Medica. 



420 ON THE TREATMENT OF INTERMITTENT FEVER. 

that cinchona and its derivatives exercise their remedial power by opposing the 
development of lower organisms, and the processes of fermentation which are 
its consequence. They appeal in support of their doctrine, to the prophylactic 
action of the salts of quinine, which, in fact, prevent individuals from taking 
fever and ague, as we shall see further on ; they appeal also to the fact of the 
presence of parasitic elements in the blood of persons affected with intermit- 
tent fever ; parasites which Laveran has of late described with great care. 5 
This last hypothesis is much the most probable, and it is as an antagonist of 
fermentation that quinine acts in this periodical febrile disease. We will now 
study what are the rules which should preside over the administration of this 
medicament. 

Cinchona occupies such an important place in modern therapeutics that 
it has been found necessary to take measures to prevent the destruction of the 
trees which furnish this precious bark. The Indians in the valleys of the 
Andes, whose business it is to gather the bark, the Cascarilleros, as they are 
called, were in the habit of destroying the trees to obtain the bark ; hence the 
rapid rise in the price of this medicine, and the danger of a complete exhaustion 
of the supply. So on all sides we have seen Europeans making efforts to culti- 
vate cinchona trees in their colonies. The Dutch, for instance, have imported 
them to Java ; the English to the Himalaya mountains, to the isle of Mauritus, 
and to Australia ; the Portuguese to the Canary Islands ; and the French to 
Martinique, to Guadeloupe, and especially to the Reunion. 

I shall not say much about the botanical characteristics of this member of 
the Rubiacese, referring you to your treatises on botany. Moreover, the num- 
ber of the true and false cinchonas is so large that their study constitutes a science 
of itself, which is called quinology. I will then only remind you that from a 
therapeutic point of view these barks are of three kinds ; the yellow cinchona 
of which the cinchona calisaya is the type ; the red cinchona, represented by 
the cinchona succirubra; and the gray cinchona, furnished by the cinchona 
condaminea. 4 The chemical analysis of Peruvian bark has furnished a great 

produced antiputrescent effects comparable to those of phenol; it arrests the process of fer- 
mentation, especially those which are caused by the microzymes. 

According to Baxter, a solution of -g-t^ arrests the spontaneous movements of the 
microzymes. According to him, the order of activity of these different alkaloids is as fol- 
lows: quinine, quinidine, cinchonidia, and, finally, cinchonine. He has also studied the 
salts of berberine, and picrate of potassa. The latter has an action as powerful as quinine. 
Baxter has also studied the action of quinine on the movements of the leucocytes; move- 
ments which are arrested when the proportion of the alkaloids is as one to 1,500. (a) 

3 Laveran's pigmented parasites, described minutely in a monograph of his on the sub- 
ject of the " Parasitic Nature of Impaludism" (Paris, 1882), are believed by Duclaux and 
Bouchardat to be simply a result of an alteration of the blood globules by bacilli, {b) 

4 At the commencement of the therapeutic employment of cinchona only the bark was 
known. The first descriptions, which were nearly complete, were made in 1737 and I739» 



{a) Baxter, on the Action of the Cinchona Alkaloids on Bacteria and the colorless Corpuscles of the 
Blood [Practitioner, Nov. 1873]. 

{5) Bouchardat on " Impaludism, its Causes and Remedies." (Bull, de Thdr., Dec. 15th, 1883.) 



ON THE TREATMENT OF INTERMITTENT FEVER. 421 

number of alkaloids. Pelletier and Caventou, in analyzing the crystallized 
product which Gomez has just made known under the name of cinchonino, 
found, in 1820, the two most important derivatives, quinine and cinchonine. 

by La Condamine and Jussieu, who obtained knowledge of the tree in Peru at Loxa. Then 
came the works and researches of Desportes, in 1742 ; of Jacquin, in 1763, in Cuba and San 
Domingo ; of Dombey, in 1776 ; of Ruiz and Pavon, in 1789, who established the botanical 
character of a great number of cinchonas of Peru. At the same epoch, Mutis studied the 
cinchonas of New Granada ; Humboldt and Bonpland, in 1801, those of Granada, Equador, 
and the northern parts of Peru ; Weddel, in 1804, those of Bolivia and southern Peru. 

Many other admirable writers were also occupied with the cinchonas, and have left re- 
markable works, whose names, even, we cannot mention here. 

The cinchonas are dicotyledonous plants of the Rubiacese family, tribe cinchoneae. They 
are sometimes trees of large size, sometimes simple shrubs ; their leaves are opposite, some- 
times smooth and shining, sometimes pubescent with large petioles and caducous stipules. 
The flowers form cymes, in corymbs or panicles; they are white or rose colored, and present 
a calyx adherent to the ovary, pubescent, with five parted limb ; a hypocrateriform corolla, 
with lanceolated lobes, smooth interiorily, and furnished along its borders with wooly hairs, 
five stamens included; the ovary surrounded by a fleshy disk, containing numerous anatro- 
pous ovules ; the style is simple, smooth, the stigma bifid. The fruit is an ovoid capsule, 
oblongate, or linear lanceolate, with septicide dehiscence ; it contains numerous seeds, im- 
bricated from below upward, surrounded at their circumference by a denticulated mem- 
braneous wing. 

The cinchonas grow at a medium altitude of 1,600 to 2,400 metres, and are met with in 
the parts of the Andes which extend from Venezuela and New Granada, about 10 north lati- 
tude, as far as Bolivia, about 19 south latitude. 

Beside these countries where the cinchonas are indigenous, other localities to-day possess 
this tree, thanks to transplantation and an intelligent culture. 

The Dutch have planted it in Java ; the English in certain dependencies of the Hima- 
layas, at Mauritius, in Australia, in St Helena, in Trinidad, and Jamaica ; the Portuguese in 
the Canary Islands ; the French at Martinique, at Guadeloupe, and with more success at the 
Reunion. Several attempts have also been made in Algiers. 

The cinchonas are very numerous, and present a variety of species. Weddel admits 33 
species (1870) and Hooker (1873) describes 36. From a geographical point of view, they are 
divided into cinchonas ; 1, of Bolivia ; 2, of Peru ; 3, of New Granada. From a commercial 
point of view in France, the cinchonas are divided into three groups, founded on their out- 
ward appearance. 

1. The gray cinchonas, the bark of which is sun-dried, shrivelled, and in the form of 
quills ; gray, rough externally, and covered by its epidermis, and certain lichens which grow 
on it ; yellow externally. It has a woody odor, an astringent savor, contains much tannin 
and cinchonine, and but little quinine. 

2. The yellow cinchonas. The bark is thick, quilled, but not rolled inwards, deep 
yellow, without odor, more bitter, less astringent, poor in cinchonia, but very rich in 
quinine. 

3. The red cinchonas. The bark is very thick, flat, or quiil-shaped, blood red color ; 
chemically, is intermediate between the two others. 

In fine authorities have admitted a further group, the white cinchonas, which contain 
but little cinchonia, and are almost inert. 

Among the gray cinchonas have been classed : 1, The cinchona of Loxa, which is fur- 
nished by the cinchona condaminea (cinchona officinalis) of Linnaeus ; 2, the cinchona of 
Huanco, in Lower Peru, or of Lima, which furnishes three principal varieties, the fine cin- 
chona of Lima, the coarse cinchona of Lima, and the white Lima cinchona ; 3, the cinchona 
Huamalis of Peru is got from the cinchona purpurea, and is little esteemed ; 4, the red cin- 
chona calisaya of Bolivia. 



422 ON THE TREATMENT OF INTERMITTENT FEVER. 

Since then there have been discovered quinidine, cinchonidine, quinamine, 
paricine, aricine, cusconine, pitoyine, etc.' 

Do not expect of me a description of all these alkaloids. I shall content 
myself with a brief reference to the principal of them, especially those which 
may in part take the place of quinine. Cinchona bark, in fact, being of rela- 
tively high price, it is apparent that quinine itself must be costly, and you will 
see, as we proceed, that this question of price has considerable importance in 
the treatment of intermittent fever, and that it is incumbent on us always to 
endeavor by a good use of the medicament to obtain the maximum thera- 

Among the yellow cinchonas we note : i, The flat or royal red cinchona calisaya, 
which is the cinchona calisaya the most diffused and best known — the officinal cinchona; 
2, the calisaya of New Granada, of which there are two species, the cinchona lancifolia and 
the cinchona pitayensis, which give barks of the first order ; 3, the cinchona carabaya, 
employed especially for the manufacture of quinine ; 4, the yellow cinchona of the King 
of Spain (of Loxa) ; it is furnished by the cinchona condaminea. 

Among the red cinchonas are : 1, The bright red; 2, the pale red of Equador, furnished 
by the cinchona succirubra of Quito, the red cinchona of New Granada or of Mutis ; 3, the 
warty red cinchona furnished by the cinchona Humboldtiana. 

The French codex admits three varieties which are obligatory on pharmacists : The 
grayhuanco cinchona (cinchona micrantha), the cinchona calisaya or royal yellow (cinchona 
calisaya), and the red warty or non-warty cinchona (cinchona nitida, or succirubra.) 

With the true cinchonas one often finds mixed certain strange or false cinchonas. 
The principal are : 1, The new cinchona, furnished by the portlandia grandifolia ; 2, the 
cinchona of Caraibes or Jamaica, furnished by the exostema caribeum; 3, the cinchona piton- 
cinchona of Martinique, of St. Lucie, or of St. Domingo, produced by the exostema floribun, 
dum ; 4, the cinchona cusco or Arica bark ; 5, the cinchona jaen (cinchona ovata) ; 6, the 
cinchona pitoxa ; 7, the cinchona of Para ; 8, the white cinchona of Payta. 

5 The cinchona barks used in medicine come from the trunk, the large, middling 
sized, or small branches of the tree. They have, therefore, a variable thickness, according 
to the part from which they are taken, and are flat and thick, or thin and curled. The 
indians employed during the cinchona bark harvest have received the name of cascarilleros. 
When they have collected a certain quantity of bark they dry it on the spot. The large 
pieces, arranged on slabs, are piled up in heaps and dried in the sun ; they are kept flat by 
the pressure of some heavy body put on top of the pile. These barks constitute the flat cin- 
chonas (quinquinas en table, en planches). 

The thin fine barks are also exposed to the sun, and curl up to form the quilled cin- 
chonas. 

The principal centres of the cinchona crop are : 1, In the republic of Equador, Loxa, 
and the environs of Chimborazo (cinchona succirubra) ; 2, in lower Peru, Huanco, Cuzco, 
Hamalies ; 3, in Bolivia ; 4, in New Granada, Pitayo, Santa Fe, of Bogota; 5, in Venezuela, 
Maracaibo. 

The principal ports of exportation are : Carthagena, Lima, Valparaiso, Arica, and 
Buenos Ayres — names that sometimes distinguish the various barks. 

The cinchona barks contain : 1, Certain alkaloids, quinine, cinchonia, quinidine, cin- 
chonidine (cinchonidia), quinamine (Hesse), paricine (Winckler), aricine (Pelletier and Cor- 
riol), cusconine (Lever Koehn), paytine (Hesse), etc. There are also : 2, Certain acids, 
quinic cinchotanic, quinovic, etc. ; 3, neutral substances, such as quinovine, cinchona red, 
etc. ; 4, a fatty matter ; and 5, an essential oil. 

According to the experiments of Howard, Fluckiger, and Carles, the alkaloids exist in 
greatest abundance in the cellular parenchyma (meso-phlceum), and the quinine is found 
especially in the external portions of the epiphlceum or corky envelope. The cinchonia is 



ON THE TREATMENT OF INTERMITTENT FEVER. 423 

peutic effect with the least quantity. This costliness of quinine explains also 
both the numerous falsifications of which this alkaloid is the subject, and the 
unwearied endeavors to find good substitutes for it. It is to be hoped that 
through the incessant progress of chemistry we shall be able in the future to 
manufacture quinine by a process of synthesis out of relatively inexpensive sub- 
almost equally diffused throughout the three layers. It is possible to increase the secretion 
and production of quinine by a process which has been put in practice by Mclvor, director of 
the English plantations in Hindostan. Having remarked that the thin barks, protected from 
the light, are richer in alkaloids than those which are exposed, Mclvor conceived the idea of 
covering the trunk of the trees with moss, and it was found that by this simple method, 
called mossing, the rendition of quinine might be quadrupled. To this mossing another pro- 
cess has been added, that of peeling. From the trunk of the tree chosen the external layer 
of the bark is removed and the place covered with moss. After suffering somewhat from the 
injury the tree recovers, and at the end of a couple of years there is obtained by this 
operation a new rind, richer in quinine than the first bark. 

The most active ingredients of the bark are quinine, then cinchonia, then quinidine and 
cinchonidia. 

Quinine was discovered in 1820 by Pelletier and Caventou. It is crystalline or amor- 
phous. Pure quinine may be obtained from calisaya bark, treated successively by hydro- 
chloric acid, lime and alcohol. It may also be procured from sulphate of quinine by decom- 
posing it by ammonia. In the first instance you obtain brute quinine, a substance of firm 
consistency, resinous, and formed of a mixture of quinine, cinchonine, fatty and coloring 
matters. Almost insipid, it is employed in powders, potions, and pills. Trousseau pre- 
scribed it to infants of two years and below in the dose of 2% to 5 grains, rolled into little 
pellets, and mixed with tapioca or sago. 

To extract from sulphate of quinine pure quinine, the Codex recommends the follow- 
ing process : Dissolve 100 grammes sulphate of quinine in 3000 grammes of boiling water. 
Having effected solution, leave the liquid to cool, and pour in sufficient water of ammonia 
to entirely decompose the sulphate. The quinine set free is precipitated. It is collected on 
a filter and washed with warm water to remove ammonia. It presents itself under the form 
of a white porous friable substance of bitter savor after desiccation. It is soluble in two 
parts, boiling (absolute) alcohol, in 60 parts ether, in 6 parts chloroform, in 400 parts cold 
water, and 250 parts warm water. It dissolves also in the fatty oils and in the volatile oils ; 
also in the concentrated mineral acids. 

On adding an excess of ammonia to a dilute solution of sulphate of quinine, you ob- 
tain crystallized quinine, which retains 3 molecules of water. This melts at i2o°C, 
losing its 3 molecules of water, and forms an oil which, on cooling, takes on the appearance 
of a resinous mass. 

Cinchonine exists in greatest abundance in the gray cinchonas. It crystallizes in large 
quadrilateral prisms, soluble in 2500 parts of boiling water, 40 parts of chloroform, 30 parts 
of boiling alcohol, and is fusible at 165 C. It forms with acids salts more soluble in water 
or alcohol than the salts of quinine. The basic sulphate of cinchonia is chiefly employed, 
and in much larger dose than sulphate of quinine. 

Quinidine, discovered in 1833 by Henry and Delondre, studied especially by Pasteur in 
1853, crystallizes in rhombric octahcedra. 

Cinchonidia, discovered in 1844 by Winckler. and called in Germany quinidine (name 
which Winckler gave it), crystallizes in rhombric prisms. 

Cinchonidia is soluble in 1680 parts cold water, 19 of alcohol, and 76 of ether. It 
melts at 2o6 c C.(a) 



(a) Pelletier and Caventou Chemical researches on cinchona. (Jour, de Pharm., t vii., Feb., 1821.) Pas- 
teur on the alkaloids of cinchona. (Paris, 1853) Prunier on the cinchonas. (Nouveau Diet, de Med., et 
Chem., 1882.) 



424 ON THE TREATMENT OF INTERMITTENT FEVER. 

stances, or, at least, to transform the less active alkaloids of Peruvian bark into 
quinine. Among these alkaloids I desire to draw your attention only to cin- 
chonine, cinchonidine, and quinidine. 

Since Pelletier and Caventou discovered cinchonine, 1 endeavors have 
been made to apply this alkaloid — which differs, as you know, from quinine only 
by an atom less of oxygen — to the treatment of intermittent fever, and 
Marianini, Girault, Pepper, Wahu, and Hudellet have affirmed that sulphate of 
cinchonine is equal, if not superior, to sulphate of quinine ; nevertheless, 
Laveran, and especially Moutard Martin, who have made of cinchonine a very 
interesting therapeutic study, have shown us that sulphate of cinchonine, while 
rendering considerable service in the treatment of paludal fevers, is yet in- 
ferior in potency to sulphate of quinine. 2 This salt, then, merits the name of 
"quinine of second quality," under which it is sold abroad. 

1 It was Pelletier and Caventou, who first discovered this alkaloid in gray cinchona 
bark about the year 1821. 

Cinchonia differs from quinine by having one atom less of oxygen : 

Cinchonia C 20 H 24 N" 2 O 

Quinine C 20 H 34 N 2 O 2 

Cinchonia forms with acids a great number of salts. Heated with potassa, it gives rise 
to several alkaloids, among them to quinoleine. 

Attempts have been made to transform cinchonia into quinine. This has not yet been 
accomplished, but quinine has been turned into cinchonia. 

Cinchonia is not soluble in ether. This enables us to separate it from quinine, which 
is soluble in this menstruum. Cinchonia is obtained from the mother liquor used for the 
preparation of sulphate of quinine. 

Certain cinchonas contain even more cinchonia than quinine. Thus the C. scorbicu- 
lata, which has in 1000 grammes 12 of cinchonia and 4 of quinine. Cinchona cordifolia 
mutis contains 12 parts in 1000 of the former to 2 or 3 of the latter ; while the C. pubescens 
has 30 per 1000 of cinchonine, and only 3 or 4 of quinine. 

2 Sulphate cinchonia was early applied to the treatment of intermittent fevers. 
Marianini, Girault, Pepper, Wahu even think it equal or superior to quinine. Briquet 
shares this opinion. 

The military physicians have bestowed much study on the comparative effects of these 
two alkaloids. Laveran regards cinchonia as much inferior to quinine. Moutard Martin has 
best summarized the action of the former : 

1. Sulph. cinchonia, administered in intermittent fever has incontestable though vari- 
able action. 

2. Sometimes its effect is rapid, it cuts short the attack like sulphate of quinine ; at 
other times it is slow, whatever may have been the dose administered, and the paroxysms 
wear themselves out little by little. 

3. The dose ought always to be large ; at least a third more than that of quinine em- 
ployed under the same circumstances. 

4 To obtain a curative action, you must employ a dose varying, according to indivi- 
duals, from 10 grains to 15. 

5. In this dose it often determines certain physiological effects which it will not be 
prudent to exceed. 

6. The therapeutic action is not in proportion to its physiological action, for it sometimes 
cures without the patient having felt its effect. In other cases where the physiological 
action is energetic the therapeutic action is nil. 






ON THE TREATMENT OF INTERMITTENT FEVER. 425 

Laborde has put in clear light the physiological difference between quinine 
and cinchonine, the latter being "more convulsivant" and determining in all 
animals to which it is administered, an aggregate of symptoms to which he has 
given the name of cinchonic epilepsy. 3 Cinchonidine (cinchonidia) and 
quinidine are isomeric respectively with cinchonine and with quinine ; 4 long 

7. It cannot replace quinine in grave intermittent fevers. 

8. It may become a precious adjuvant to quinine; in completing the cure begun by one 
or two doses of the latter. In this way you may economize quinine, which is much the 
more expensive, (a) 

3 Magendie was the first to study the physiological and toxic action of the salts of 
cinchonine (cinchonia), and concluded from his experiments that this alkaloid was not toxic. 
According to Briquet, cinchonine and quinine differ only by the intensity of their effects, 
sulphate of quinine manifesting a toxic power double that of sulphate of cinchonia. These 
results have been contradicted by the experiments of Bouchardat, Delondre, and Girault, 
who have found the toxic power of cinchonia far superior to that of quinine. 

Berandi regards sulphate of cinchonia as an excitant. See and Bochefontaine, in their 
recent physiological experiments, have arrived at the same conclusions as Briquet, and 
consider quinine as more active and more toxic than cinchonia. Both substances, accord- 
ing to them, are convulsivant; cinchonia the most so. Ten grammes of sulphate of quinine 
injected subcutaneously, would put the life of a man in the same jeopardy as 16 grammes of 
sulphate of cinchonia. 

According to Laborde, what characterizes the toxic action of cinchonia is the production 
of epileptiform convulsions, described by him under the name of cinchonic epilepsy. These 
symptoms follow 25 centigrammes in a guinea-pig weighing 250 to 300 grammes, and 75 
centigrammes in a dog weighing 12 kilogrammes, after subcutaneous injections, {b) 

4 Cinchonidia was first distinctly separated from quinidine by Pasteur. Its formula 
is as follows: 

C 30 H 24 N 2 O 1 . 

It is isomeric with cinchonia. This alkaloid seems to predominate in certain barks of 
cinchona, as Winkler has shown. It is scarcely soluble in water and ether, and combines 
with acids to form a series of salts; it is laevogyrus (polarization being left-handed). Accord- 
ing to Laborde, the physiological and toxic action of cinchonidia is as follows: The animal 
is taken at first with a trembling similar to that of paralysis agitans, then with an attack of 
epilepsy resembling that produced by cinchonia. 

Chirone and Curci have arrived at like results. They find cinchonidia more active than 
quinine and its toxic power greater. It produces epileptiform convulsions, which are the 
more intense the higher the animal is in the zoological scale, and the more developed his 
brain; it acts more especially on the motor cortical centres and leaves intact the spinal. 

Gubler has employed the dibromhydrate of cinchonidia in subcutaneous injections. 
This salt, obtained by Petit by decomposing sulphate of cinchonidia by barium bromide, is 
in fine prismatic crystals of feeble yellow color, and having for formula : 



(a) Laveran, Etude sur Taction comparee du sulfate de quinine, du sulfate de cinchonine et du qui- 
nium dans le traitement des fievres intermittentes d'Afrique (Gaz. med de Paris, 1856).— Hudellet, Etude com- 
parative des deux sulfates de quinine et de cinchonine dans le traitement des fievres intermittentes (Ann. 
ther de Bouchardat, 1856, p. 121).— Corps de same" militaire, Resultats de l'experimentation faite dans les hopi- 
taux militaires sur les succ^danes de la quinine (Rec. de med., de chir. et de pharm. militaires, 3e s^rie, t. II, 
1859). — Moutard Martin, Memoire sur la valeur du sulfate de cinchonine dans le traitement des fievres inter- 
mittentes (Mem. de l'Acad. de med., t. XXIV, i860. 

(6) Briquet, Therapeutical Treatise on Cinchonia and its Preparations, Paris, 1853. Bouchardat, Delondre 
and Girault, Physiological and Therapeutical History of Cinchonia. Magendie\ Jour, de Pharm., Vol. VII, p. 
138. See and Bochefontaine, on the Toxic Power of Quinine and Cinchonine. Compt. Rend, de l'Acad. des 
Sc, 1883, No. 96, p. 266. 



426 ON THE TREATMENT OF INTERMITTENT FEVER. 

confounded together under the name of commercial quinidine, it is to the 
brilliant researches of Pasteur on the alkaloids of cinchona that we owe their 
definite separation. Like cinchonine, they are, from a toxic point of view, con- 
vulsivant ; from a therapeutic point of view they antagonize morbid periodi- 
city. Cinchonidine especially, according to the observations of Gubler, Wessell, 
Bouchardat, Coletti, and Bourru, is equal, and even superior to quinine in the 

C40 H24 N2 O2 HBr. + 4 H 2 O. 

The solution which Gubler used for hypodermic injections is as follows: 
Take of: 

Dibromhydrate of cinchonidia 10 grammes. 

Distilled water, q. s., to make 50 cubic centimetres. 

Each syringeful containing one cubic centimetre, represents twenty centigrammes of 
the active principles. These injections have an action (according to Gubler) equal to that of 
sulphate of quinine. 

Palcolo Machiavelli has made use of sulphate of cinchonidia in 851 cases. He claims 
the same results as are obtained from sulphate of quinine. 

Le Judge, of Mauritius, considers sulphate of cinchonidia just as efficacious as sulphate 
of quinine in the treatment of intermittent fevers; it is well tolerated by the stomach, and 
produces neither buzzings in the ears nor nervous troubles. Weddell has pointed out the 
importance of cinchonidia in the treatment of malarial fevers at Madrid and the East Indies. 
He gives statistics relating to 1145 patients treated by cinchonia, cinchonidia, and quinidine; 
the therapeutical results were similar with all of them; he maintains, therefore, that it 
would be well to substitute cinchonidia for quinine. 

Coletti has studied the physiological and therapeutical action of cinchonidia. This 
substance, while producing convulsions, did not, in his experiments, produce veritable 
epileptic attacks as in the experiments of Laborde and Dupuis. In his estimation, cincho- 
nidia is equal, therapeutically, to quinine. 

According to Bourru, who has also made comparative trials with quinine and cincho- 
nidia in malarial fever, the latter produces, generally, favorable results, being unattended 
with vertigo and other accidents. Out of twenty-seven cases, cinchonidia arrested the 
attacks in twenty-four. The same dose was given as of quinine. The alkaloid should be 
given six or seven hours before the probable onset of the paroxysm. 

Quinidine was brought to notice for the first time by Henry and Dilondre, in 1833. 
Pasteur, in his work on the alkaloids of cinchonia, has shown that under the name of quini- 
dine is found in commerce a mixture in variable proportions of cinchonine, of quinine, of 
cinchonidia, and of quinidine. Quinidine and cinchonidia are very often confounded. This 
quinidine forms with the acids certain basic and acid salts. 

Wunderlich, in 1865, was the first to experiment with quinidine. These trials were 
resumed in 1878, by Machiavelli. This medicament, in the dose of about a scruple, caused a 
fall in the temperature equal to that of quinine. Its antipyretic properties in fevers were 
found equal to those of quinine, only it produced vomiting, which was readily met by 
opium. 

According to Laborde, quinidine produces, like cinchonidia and cinchonia, epileptic 
attacks in toxic doses; that is to say, in doses of from 20 to 25 centigrammes for a guinea 
pig weighing from 350 to 400 grammes. 

Dougall, at Madras, has experimented comparatively, with quinidine, cinchonidia, and 
cinchonia. It results from these researches, that quinidine has the first place in order of 
efficacy, then cinchonidia, then cinchonine. (a) 



(a) Dougall, on the Febrifuge properties of Cinchonia, Quinidine, and Cinchonidia (Edin. Med. Jour., 
Sept., 1873). Laborde, These de Paris, 1883. 



ON THE TREATMENT OF INTERMITTENT FEVER. 427 

treatment of paludal fevers ; so interested pharmaceutical firms, in captivating 
pamphlet monographs, urge on the profession the substitution of cinchonidine 
for quinine, and this especially by reason of its cheapness. 

By the side of these alkaloids I will mention quinoleine (chinoline) 1 and 
quinoidine (chinoidine). The first has this character, that it has been obtained 
by way of synthesis, and that this body, which forms a part of the aromatic 
series, and which furnishes, as you know, kairine, serves as intermediary between 
the alkaloids of cinchona and the antipyretic medicaments of the group of 
phenols and oxy-phenols. If we can trust the experiments of Loewy, this 
quinoline has an anti-periodic action of the most marked kind. 

As for quinoidine it is not, properly speaking, a genuine alkaloid, but 
rather a combination of all the alkaloids which remain in the mother liquid 
after the preparation of quinine. Burdell, of Vierzon, continuing the experi- 
ments of Natorp, at Berlin ; of Fraser, in Ohio ; of Ossieur and Vanoye, in 
Flanders, has shown all the advantages which may be derived from quinoidine 
in the treatment of intermittent fever of the quartan form, especially in the tel- 
luric cachexia. Unhappily this substance, which is of low price, presents a 
varied composition, and it is easily understood that, according to the process of 
preparation, you obtain different quinoidines. 2 

Having concluded this rapid survey of the alkaloids of cinchona, I hasten 
to the most important of them, viz., quinine. I have already spoken to you of 
its physiological action; it remains to consider the question of its absorption and 
elimination. 

Quinine has a local irritant action which is indubitable. The most marked 
proof of this is the multiple eruptions with which operatives are affected 
who are occupied in the manufacture of quinine. This irritant action is also 

1 Quinoleine, obtained by Gerhardt by distilling cinchonia with quinine and potassa, 
is a body analogous to leucol, which Runge extracted from coal tar, in 1843. It has been 
experimented with by Donath. It is given in the same doses as quinine, and is said to pro- 
duce the same effects. Loewy claims good results from it in intermittent fever, (a) 

2 Sertuerner was the first to designate under the name of quinoidine an uncrystallizable 
and alkaline substance obtained from the mother liquid employed in the preparation of qui- 
nine. It is a mixture of quinine, cinchonia, cinchonidia, and quinidia. It has been 
employed by Natrop, of Berlin, Fraser, of Ohio, Ossieur, in Belgium, etc. Briquet has 
noted the same action from this substance as from sulphate of quinine. 

Burdel employs quinoidine, and considers it superior to quinine in chronic malaria. 
He gives it pure, or in the form of soluble sulphate; prescribing from eight to fifteen grains 
to an adult, and continuing the treatment for several weeks in gradually increasing and 
rather infrequent doses. Administered in this way, Burdel thinks that he finds in quinoidine 
a more powerful febrifuge than quinine in the treatment of quartan fevers and malarial 
cachexia, (b) 



{a) Loewy, Wein. Med. Presse, No. 39, 1881. Gerhardt, Revue Scientifique, t. x, p, 186. Runge, Pogg. 
Ann., t. 31, p. 68. 

(b) Stertuernerner, Ueber die neuest. Fortschrift in d. Chem. Phys. u. Heilk., t. Ill, p. 269). Ossieur et 
Vanoye, De la quinoidine dans le traitement des fievre intermittentes (Ann. de la Soc. mdd. d'^mul. de la 
Flandre occidentale, mai 1848, et Bull, de the"r., t. XXXV, 1848, p. 43). Briquet, Traite therapeutique du 
quinquina, 1853, P- 4^9- Burdel (de Vierzon), Du traitement des fievres intermittents telluriques par la quin- 
oidine (Un. med., 30 novembre et 5, 7 et 9 decembre 1878). 



428 ON THE TREATMENT OF INTERMITTENT FEVER. 

manifested on the mucous membranes, and this explains to you the gastric and 
intestinal disturbance which is produced when we give quinine salts by mouth 
in too big doses or too prolonged doses. This same local irritant action of the 
salts of quinine explains also why it is that subcutaneous injection of quinine 
solutions may be the point of departure of indurations and even suppurations. 
When quinine enters the stomach it is dissolved by the acid of the gastric 
juice, and it is probably in the state of hydrochlorate or of lactate of quinine that 
this alkaloid is absorbed. At the same time, when quinine salts of the veget- 
able acids are given, they are changed to carbonates in the blood. 1 Quinine 
and its salts, after being absorbed, are forthwith eliminated by the various 
emunctories, and in particular by the kidneys. As Kerner has well shown, this 
elimination is the more active and more prompt the more soluble the salt of 
quinine, 2 From this fact we may adduce a very important conclusion, viz., 
that the activity varies with the solubility of the preparations, and hence we 
should choose those saline combinations of quinine which are the most soluble. 



1 According to Briquet and Quevenne, the salts of quinine pass unchanged into the 
blood when their acid is undecomposable; when the acid is decomposable, as is the case with 
the vegetal acids, it passes into the blood in the state of carbonate. Miahle even thought 
that quinine must always be set free in the blood by reason of the carbonic acid of that fluid 
liberating it from its saline combinations, but Delioux, of Savignac, shows this theory to be 
inadmissible, and that the sulphate of quinine must remain as such in the liquor sanguinis 
without undergoing any decomposition, (a) 

2 The following is the reagent proposed by Bouchardat for the detection of the alka- 
loids of cinchona in the urine: 

I£ Iodine 15 parts. 

Iod. pot 4 " 

Water 300 ' ' 

M. 

Briquet's modification of the above, which shows well the precipitate, though less deli- 
cate, is as follows: 

J£ Iodine 1 part. 

Iod. pot 4 parts. 

Water T25 " 

M. 

These liquids give an orange red precipitate of ioduret of iodohydrate of quinine, of 
cinchonia, etc. 

We here give Kerner's table, showing the rapidity of elimination of the various alka- 
loids of cinchona: 

The figures indicate the proportion of quinine eliminated in the urine for 100 parts of 
the alkaloid contained in the dose employed — 



(a) Briquet, Therapeutical Treatise on Cinchona, 1853. Delioux of Savignac, Art. Quinine in Diet. 
Encyclop. des Sciences Med. 



ON THE TREATMENT OF INTERMITTENT FEVER. 429 

These quinine salts are very numerous, 3 as you can judge by the following 
table, made at my request by Tanret. This table contains the quinine com- 
binations most in usage, classed according to the quantity of base which they 
contain, for you easily understand that the activity of a quinine salt depends on 
the one hand on its solubility, and on the other on the quantity of the alkaloid 
which it possesses, and you see what an elevated rank the chlorhydrate of 
quinine occupies in comparison with the sulphate. 



DATE OF THE EXAMINATION OF THE URINE AFTER TAKING THE MEDICINE. 



V 


4) 


<u 




















3 

a 


3 

c 

a 


3 

c 

a 


u 

o 
,C3 


t/2 
U 

o 


w 

O 


to 
l-i 

O 


l-l 

O 
^5 


u 

O 


O 


en 
O 


O 

^3 


LO 


o 

en 


<* 


M 


en 


o 


N 


tf 

a 


CO 


oo 


O 

IT) 


a 

O 


I 


4 


4 


8 


15 


19 


30 


12 


2 


I 





o 





i 


2 


6 


14 


26 


19 


16 


6 


2 





o 


o 





5 


6 


13 


25 


18 


15 


8 


4 


I 


o 


I 


4 


4 


IO 


12 


22 


15 


12 


10 


3 


o 


o 


o 


2 


c 


6 


13 


27 


16 


12 


8 


3 





o 


o 


I 


4 


7 


15 


29 


14 


10 


7 


4 


I 


o 


o 





o 


o 


i 


2 


9 


28 


14 


4 


2 


2 



Chloride of quinine dissolved in 

gaseous water 

Bisulphate of quinine 

Sulphate of quinine 

Carbonate of quinine 

Acetate of quinine 

Citrate of quinine 

Tannate of quinine 

Instead of employing the test proposed by Bouchardat, Kerner utilizes the fluorescent 
properties of solutions of quinine in order to determine the most minute quantities of this 
alkaloid contained in the urine, (a) 

3 Quinine is an energetic base, which readily enters into combination and forms 
crystallizable salts. These salts, less soluble than those of cinchonia, are very bitter. They 
are incompatible with alkaline hydrates, ammonia, iodureted iodide of potassium, tannin, 
double iodide of potassium and mercury, etc., which precipitate them from their aqueous 
solutions. We may divide the quinine salts into three groups: 

i. Those perfectly soluble (the bisulphates, chlorhydrates, lactates). 

2. Those less soluble (the neutral sulphates, acetates, valerianates). 

3. Those little, if at all soluble (the phosphates, ferro-cyanates, arsenites). 

The salts the most soluble are also the most active. We shall here specify a few of the 
most known of these salts: 

Sulphate of quinine. — There are two sulphates: the neutral and the acid sulphate. The 
neutral sulphate crystallizes in prismatic, white, silky needles. Is efflorescent, inodorous, 
very bitter, little soluble in water (740 parts of cold water and 30 of boiling water being 
required); almost insoluble in ether, very soluble in glycerine, soluble in 60 parts of cold, 
absolute alcohol. Solution in water is favored by a drop or two of some strong acid. 

The acid sulphate, or bisulphate, crystallizes in rectangular prisms. Is soluble in 11 
parts of water at 59 F., making an intensely bitter solution. On account of its high price, 
various falsifications have been resorted to: 1, salicine, which may be detected by adding 
concentrated H 3 SO 4 to the suspected preparation, in presence of salicine it gives a red 
coloration; 2, sugar, which blackens under sulphuric acid; 3, stearine; dilute sulphuric acid 
does not completely dissolve the salt; 4, starch and magnesia; the preparation containing 
these adulterations would not completely dissolve in alcohol. Recently, sulphate of quinine 
has been largely adulterated with sulphate of cinchonidia. 



(«) Briquet, loc. cit. Kerner, Pfluger's Arch. f. die Gesammte Physiologie, 1870. 



430 ON THE TREATMENT OF INTERMITTENT FEVER. 

The sulphate is the salt most employed, at least in France. It is one of 
the most stable combinations, but which presents the inconvenience of being 
little soluble when neutral ; so whenever you wish to administer the sulphate in 
potion you must make it into a soluble bi-sulphate. Regnault has, moreover, 
furnished the most precise indications in regard to the solubility of this salt. 4 

Lactate of quinine crystallizes in flat, silky needles; savor is disagreeable; therapeutic 
action feeble. 

Tartrate of quinine. — There is a neutral tartrate and an acid tartrate; the latter is very 
soluble and crystallizable. 

Acetate of quinine is very soluble in boiling water, though little soluble in cold water. 
Is much employed in Germany. 

Arseniate of quinine. — White, soluble in water and dilute alcohol. Is given in doses of 
2, 4, and 6 centigrammes a day. 

Iod-hydrate of quinine occurs in white, opaque, lamellated crystals. 

Valerianate of quinine. — Octadsedral crystals, of bitter taste, slightly soluble in cold 
water, very soluble in alcohol. Dose, 20 to 50 centigrammes (2 to 9 grains), in intermittent 
fever. 

Tannate of quinine. — An amorphous, yellow-white powder, little soluble in water, 
more soluble in alcohol. Almost tasteless. 

Phosphate of quinine. — Crystallizes in needles. Little soluble in cold water, soluble in 
alcohol. Dose, 5 to 20 centigrammes. Is employed in Italy. 

Citrate of quinine. — Crystallizes in needles. Little soluble. Is employed in Italy. 
Dose, 20 centigrammes. 

Ferro-cyanate of quinine. — Crystallizes in needles. Little soluble in water, soluble in 
alcohol. Employed in Italy in pill form. Dose, 20 to 40 centigrammes. 

PERCENTAGE OF QUININE IN DIFFERENT SALTS OF THE ALKALOID. 

Percentage of 

Anhydrous 

Quinine. 

Acetate of Quinine C 30 H 24 N 3 O 3 C 2 H 4 O 3 87.34 

Hydrate of Quinine (Quinine precipitated and dried) C 20 H 24 N 2 O 2 3H 2 O. . 85.70 
Basic Chlorhydrate of Quinine — the sole chlorhydrate employed, the Neutral 

Chlorhydrate not being stable — C 30 H 24 N 3 O 2 ,HC1.2H 2 O 81.60 

Lactate of Quinine C 30 H 34 N 3 O 3 C 3 H6O 3 78.26 

Basic Bromhydrate of Quinine C 30 H 34 N 3 O 3 BrHH 3 O 76.60 

Valerianite of Quinine C 20 H 24 N 2 O 2 (C 5 H 10 O 2 ) 76-°5 

Basic Sulphate of Quinine (the ordinary sulphate) C 20 H 24 N 3 O 3 SO 4 H 3 , 7 

H 3 74.30 

Sulpho Vinate of Quinine C 30 H 34 N 3 O 3 SO 4 C 3 H 6 72. 

Neutral Bromhydrate of Quinine C 20 H 34 N 3 O 3 BrH 3H s O 60. 

Neutral Sulphate (or acid sulphate) C 30 H 34 N 2 O 2 SO T H 3 8H 3 O 57.24 

Tannate of Quinine C 20 H 24 N 3 O 8 (C 14 H 10 O 9 ) 20.60 

4 Regnauld has studied the solubility of sulphate of quinine, and these are the 
results: 

One gramme (15 grains) of sulphate of quinine dissolves in two litres (Oiv) of water at 
59 F.; 560 grammes (§ xix) in the same quantity of water at 212 F.; one gramme is solu- 
ble in 1. 133 grm., of absolute alcohol at 59 F.; in 1.926 grm., of chloroform at 59 F.; in 
22.632 grm., of ether, at 59 F. 

One gramme (15 grains) of tannate of quinine demands for its solution 20 litres (5 gal- 
ons) of water. 



ON THE TREATMENT OF INTERMITTENT FEVER. 431 

If the sulphate is the most use in France, it is the chlorhydrate which is em- 
ployed the most in England and in Germany. 1 This salt, in fact, is more 
soluble than the sulphate, and contains more quinine, so that, according to the 
rules previously laid down, it would be better to employ the chlorhydrate, and 
this is a point worthy of remembrance. As for the acetate, which contains so 
large a quantity of base, it is too unstable a salt for constant use. 

In combining salicylic acid with quinine the intent has been to increase 
the antipyretic power of this medicament, 2 and notwithstanding the very inter- 
esting experiments of Maury, of Lyons, and the therapeutic results of Graham 
Brown and of Antonescu, the usage of this salt is very limited. 

Of all the salts of quinine the most stable is the tannate. 3 and it has been 
claimed that it may even traverse the economy without undergoing decomposi- 
tion. At the same time the experiments of Kerner and especially of Vulpian 

1 There exist two combinations of quinine with hydrochloric acid: one neutral, which 
is not stable, and a basic salt, which has the following formula : 

2 (C 20 H 24 N 2 O 2 , Hcl) + 3 H 2 O. 

This salt crystallizes in long, silky fibres; it is more soluble in water than the sulphate; 
it contains also more quinine. 

2 Salicylate of quinine has the following atomic formula : 

C 20 H 24 N 2 O 2 C 7 H 8 C 20 H 34 N 2 O 2 C 2 H 6 O 3 . 

It crystallizes in silky tufts; is soluble in 1430 parts of water at 68° F., and in 100 parts 
of boiling water. It has been especially studied by Graham Brown (Edin. Med. Journ. Nov. 
1876, page 421), who considers it a very active antipyretic medicament. 

Maury, of Lyons, has made some interesting experiments with this salt, showing its 
great antiseptic power. 

German See has also experimented with this salt in his hospital service in intermittent 
fevers and typhoid fever, but with indifferent success. Antonescu, however, claims good 
effects from this salt in malarial fevers. 

3 Tannate of quinine was described for the first time in 1821 by Pelletier and Caventou 
under the improper title of gallate of quinine. This salt contains 26 percent, of quinine and 
3.50 grm., of the tannate (52^ grains) corresponds to one gramme (fifteen grains) of the 
sulphate. 

Regnauld's process of manufacture (Journ. de Pharm. et de Chim. t. xix, 1879) gives a 
preparation with the following formula: 

c 40 H 24 N 4 2 (C 54 H 22 O 34 ). 

Becker, of Bonn, considers tannate of quinine as a good medicament. He has 
especially derived benefit from it in whooping cough. Hagenbach also considers tannate of 
quinine as a good febrifuge. It combats the fever and diarrhcea of typhic patients. 

Vulpian has shown that tannate of quinine is absorbed and eliminated. At the 
same time this medicament has a very feeble action. It is especially beneficial in 
preventing profuse sweats (Delioux, of Savignac.) It may also be employed in infantile 
diseases, (a) 



(a) Regnauld, On tannate of quinine, in Jour, de Pharm et de Chem., 1879. — Vulpian, On tannate of 
quinine (Acad, de Med., 1872). — Delioux, of Savignac, On the employment of tannate of quinine in the treat- 
ment of night sweats (Un. Med., 1853.) 



432 ON THE TREATMENT OF INTERMITTENT FEVER. 

show that it does undergo decomposition, though very slowly; it is then one of 
the least active preparations. 

As for the bromhydrate,"it is to-day chiefly employed in subcutaneous in- 
jections, and I shall return to this salt when I come to speak of the hypodermic 
use of quinine. 

To introduce these salts of quinine into the economy, we can make use of 
several ways; the stomach, the intestine, the skin, the subcutaneous cellular 
tissue and the lungs. In giving it by mouth you can administer it in solution, 
in suspension, in powder or in pills. By very careful experiments Briquet 1 has 
shown us that the solution is the most prompt and certain of these forms of ad- 
ministration, and the pill form is the worst. 

In making your solution 2 you should either prescribe the bisulphate or 
order enough of sulphuric acid to effect the change into a soluble bisulphate. 

1 Briquet has made comparative trials of solutions, powders and pills containing 
sulphate of quinine. He endeavored to ascertain by the presence of quinine in the urine 
the rapidity of absorption, and by the manifestations of encephalic troubles, the action on 
the nervous system. These are his conclusions: 

Complete solution. — ist. There is manifested at the end of from two hours and a 
half to three hours after the ingestion of the solution of bisulphate of quinine, signs of 
absorption in two-fifths of the patients who took fifteen centigrammes (2% grains); in about 
two-thirds of those who took from 20 to 25 centigrammes (3 to 4 grains), and in three- 
fourths of those who took from 30 to 35 centigrammes (5 to 6 grains). 

2d. There were manifested signs of action on the encephalon in one-fifth of the patients 
who took fifteen centigrammes {2% grains) ; in a little more than one-third of those who took 
twenty centigrammes (3^3 grains); in more than two-thirds of those who took 25 centi- 
grammes (4 grains), and in three-fifths of those who took 50 centigrammes (yj4 grains). 

In the case of the administration of the pulverulent form, these we?e the results: — 
ist. There were no signs of absorption at the end of three hours save in one-fifth of the 
patients who had taken 25 centigrammes (4 grains); in one-sixth of those who had taken 30 
centigrammes (5 grains), and in one-fourth of those who had taken 35 centigrammes (6 
grains); a degree of absorption which considered en masse is not equal to that of 15 centi- 
grammes {2% grains) of acid sulphate in solution. 

2d. There were no signs of physiological action in at least one-third of the patients 
who had taken 25 centigrammes (4 grains) of neutral sulphate in powder, in one-sixth of 
those who had taken 30 centigrammes (5 grains), and in a little less than one-third of 
those who had taken 35 centigrammes (6 grains). This degree of action, taken as a whole, 
is less than that of 15 centigrammes {2% grains) of bisulphate in solution. 

Administration of quinine hi pill form. — ist. With the pill form there did not exist at 
the end of three hours any signs of absorption of quinine except in a very feeble proportion 
which might be approximately estimated at one-sixth as many as were markedly affected 
when the same dose was given in solution. 

2d. The signs of absorption observed at the end of two hours were noticed in a larger 
proportion than in the case of those to whom the quinine salt was given in powder (as 2 to 
3) but in less proportion than where the quinine was given in solution (as 4 to 5). 

3d. Whatever may have been the dose in the pill form, no physiological action on the 
nervous system was ever noted, (a) 

5 Below are several formulae for potions of sulphate of quinine : 



{a) Briquet, Therapeutical Treatise on Cinchona and its Preparations. Paris, 1853. 



ON THE TREATMENT OF INTERMITTENT FEVER. 433 

You can use tartaric or citric acid in making your solution, or you can do as 
Herard directs, dissolve your quinine in a small wineglassful of brandy or rum. 

Unfortunately, all these active preparations have the disadvantage of being 
exceedingly and persistently bitter to the taste. One of the best means of 
getting rid of this inconvenience is to give immediately after the draught a little 
licorice powder. Bear in mind that when you wish to obtain a speedy effect, 
and utilize the whole of your dose of quinine you must give it in solution. If 
you choose to give it suspended in some liquid menstruum you cannot do better 
than administer it in strong coffee, which well disguises the bitterness of the 
salt. This form, however, is less active than the preceding, as a certain quan- 
tity of the sulphate remains adherent to the cup, and a part is transformed into 
tannate of quinine, a combination, as above stated, ill-fitted for absorption. 

The pulverulent mode has been recommended in order to obviate the 
bitterness of the quinine, which is given in capsules or. in pearls. If the ad- 
ministration of the salts of quinine is rendered easier by this means, there are 
the inconveniences attending it that the therapeutic action is less prompt than 
with the solutions, and the direct contact of the powder of quinine with the 
gastric mucous membrane is apt to be attended with a sensation of heat and 
burning. So whenever you resort to this convenient way of giving quinine, 
recommend to your patients to drink after each dose a tumblerful of tartaric or 
citric lemonade, which effects the solution of the quinine. 

The pill form, as I have said, is the worst, by reason of the tardy solution 
of these pills. 3 I advise you, then, if you have occasion to give quinine in pills, 
to see that they are made with some soluble excipient, as honey or conserve of 



GRAMMES. 

(i) I£ Sulphate of Quinine 50 

Acid tannic 60 

Distilled water 60.00 

Syrup of ginger 3.00 

M. For one dose in malarial fevers. 

(2) 1$, Sulphate of Quinine 75 

Acid tannic 10 

Acid sul phuric gtt. ij- 

Distilled water 100.00 

Syrup of orange 40.00 

M. The whole would be a full dose. 

(3) 1$ Sulphate of Quinine 1 . 00 

Acid sulphuric, q. s. 

Water 100. 00 

Syrup, 

Syrup poppies aa* 20 . 00 

M. The above represents one full anti-malarial dose for an adult. 



Formulae for quinine pills: 



^ Quiniae sulph 1. — 

Acid tartaric 20 

Conserve of red roses 10 



M. Ft. pil. No. x. 

§28 






434 ON THE TREATMENT OF INTERMITTENT FEVER. 

red roses, and not of gum arabic, which is hard to undergo solution in the 
digestive fluids. 

In certain cases, either because the patient has an invincible repugnance to 
the quinine potions, or because he cannot take the capsules or pills, as in the 
case of young children, it has been proposed to give the quinine in enemas. 
Briquet 1 has shown us that the action of the medicine is often more rapid by 
this method than by the mouth, but much less persistent; you can then order 
enemata of sulphate of quinine, having care to change the sulphate into bi- 
sulphate, 5 but to insure their activity these injections should be kept up, and 
you know how difficult this is when your patient is a child. So in cases of this 
kind it has been advised to administer the quinine by lotions and pomades, 
thus making use of the skin as a channel of introduction. This is a means that 
will give disappointment, for it has been demonstrated that the skin covered 



5 Quinise sulph 10 

Citric acid, pulv 20 

Honey 05 

Starch q. s. 

M. For one pill. 

3 Quinise sulph 60 

Ext. Absinthe . q. s. 

M. Ft. in pil. No. vi. 

Starke has also proposed to give quinine in pill form with tartaric acid and sugar. The 
patient should drink freely of tartaric acid lemonade before swallowing these pills. 

4 Briquet, in giving lavements containing one half gramme of quinine to fever patients, 
has observed: 

1. That generally sulphate of quinine given in lavements is absorbed. 

2. That this absorption is very prompt, and twice as rapid as by the stomach. 

3. But it is too feeble, and insufficient in three-fourths the cases to determine appreci- 
able effects on the encephalon and heart. 

4. That finally absorption abruptly and completely ceases in most cases after an hour 
and a half. 

Hence Briquet considers lavements of sulphate of quinine as of only secondary import- 
ance, and to be efficacious they must be given at the very moment even when their thera- 
peutic effect is desired, (a) 

5 The following is a good formula for a quinine lavement : 

^ Sulph quinine gr.x. 

Acid sulph gtt.i. 

Warm water § v. 

Tinct Opii gtt.x. 

M. Quinine is used in suppositories ; seven or eight grains being incorporated w.kh 
sufficient cacoa butter to form a suppository. This method is not to be recommended. 

Where this salt cannot be borne by the stomach, or as an adjuvant to its internal 
administration, it may be rubbed up with lard and a little alcohol, in the form of an 
ointment, one drachm being incorporated with half an ounce or an ounce of the fatty 
excipient. 



(«) Briquet Loc. Cit., p. 338. 



ON THE TREATMENT OF INTERMITTENT FEVER. 435 

with its epithelium does not absorb the salts of quinine, or if it absorbs them, 
it is in such trifling quantity that no therapeutic result can be obtained. 

But if the skin does not absorb, the cellular tissue, on the contrary, lends 
itself rapidly to the introduction of the salts of quinine, and the hypodermic 
method finds in the paroxysms of pernicious fever one of its most useful appli- 
cations. You will see, in fact, as I shall further on point out, that there are 
cases of paludal intoxication when it is necessary to act with extreme rapidity, 
and you understand of what utility must be in these cases the subcutaneous in- 
jections of quinine, which to promptitude of absorption add a great therapeutic 
activity. Albertoni and Ciotto, 1 by their brilliant experiments on the channels 
of elimination of quinine, have shown us that this medicament, when it is intro- 
duced by the mouth, passes through the liver, and a certain quantity sojourns 
there, to be eventually eliminated in the bile; while, when introduced by the 
hypodermic method, quinine salts pass immediately into the circulation and are 
eliminated by the urine. 

Only, as these salts to be soluble must be acid, it is easy to see that such 
injections introduced under the skin may determine there local inflammations; 
therefore, endeavors have been made by Albertoni and Ciotto by the addition 
of glycerine or tartaric acid, 2 or by seeking more soluble salts of quinine, to 
render these solutions less irritative. Tanret has recommended the lactate of 
quinine, 8 of which he dissolves one part in five parts of distilled water. Paul 

1 Pietro Albertoni and Francesco Ciotto have especially studied the channels of 
elimination of quinine. They have found it in the bile from two to five hours after its inges- 
tion in the stomach. When the salt is introduced in other ways it does not appear in the 
bile, but in the urine. They have found it in the blood during the first hour after its inges- 
tion. Quinine sojourns long in the blood, and may be found in all the viscera, and in parti- 
cular in the spleen, liver, and brain. (a) 

2 Reynolds has proposed the following solution for hypodermic injection : 

Grammes. 

3 Quin sulph 28. 

Acid sulphuric q. s. 

Glycerine 24. 

Water q. s. to complete 170 cubic centimeters. 

Each cubic centimeter (syringeful) contains 16.7 centigrammes of sulphate of quinine. 
Kobner prefers the hydrochlorate, as in the following solution: 

Grammes. 

9 Hydrochlorate of quinine 1 . 

Glycerine 

Distilled water, aa 2. 

M. Dissolve without acid. One cubic centimetre contains 15 centigrammes hydro- 
chlorate of quinine. This solution keeps well in a warm room. Should be injected tepid. 

3 The following is Tanret's formula : 



(a) Pietro Albertoni et Francesco Ciotto, Sur les voies d'elimination electives de la uinine (Gaz. med # 
ital., provi Venete, 18 mars 1876, p. 93, et Bull de th£r., t. XC, 1876, p. 360). 



436 ON THE TREATMENT OF INTERMITTENT FEVER. 

advises the soluble sulpho-vinate of quinine, unfortunately of little stability. 
Generally the bromhydrate is the salt employed. 

Described by Latour and Boille, 4 this salt was introduced into therapeutics 
by Gubler, and since then we have seen Soulez, of Romarantin; Dardenne, of 
the Isle of Mauritius, and Auliffe extol the effects of this salt in the treatment 
of intermittent fevers. As the bromhydrate contains more quinine than the 
sulphate, and is more soluble, it is no wonder that it has been utilized for 
hypodermic injections, and solutions have been made of one part in ten. Bat 
in such large doses, it is necessary to add alcohol, which renders this solution 
somewhat more irritating. 

Finally, struck by the rapidity of action of medicaments introduced by the 

Grammes. 
^ Lactate of quinine I . 

Distilled water q. s. to complete 5 . 

This solution, which is stable, contains in each cubic centimetre 20 centigrammes of 
lactate of quinine. 

4 The combination of bromhydric acid and quinine was made in 1870 by Latour and in 
1872 by Boille. The formula of neutral bromhydrate of quinine is as follows: 

C 48 H 84 N 8 4 Hbr,2H 8 

That of acid bromhydrate is: 

C 48 H 24 N 2 4 2Hbr,6H 3 

This substance is crystalline, and its solubility is greater than that of sulphate of 
quinine ; one part of bromhydrate being soluble in 5 parts boiling water, or 60 parts cold 
water; it contains more quinine than the sulphate. 

Gubler has employed this salt in subcutaneous injections, using ten per cent, solutions 
in water slightly dosed with alchol ; one gramme of this solution contains one decigramme 
of the active principle ; it suffices to inject two syringefuls, in order to introduce into the 
organism the equivalent of 30 centigrammes of sulphate of quinine. 

Soulez was one of the first to make use of this salt subcutaneously in fever and ague. 
In his experience in the fevers of Sologne it proved superior to sulphate of quinine. Given 
one hour before the paroxysm, it prevented its occurrence. Moreover, in the dose of half a 
gramme to a gramme it produced little of the quinine intoxication. He has recommended 
this method of subcutaneous introduction: Plunge the needle directly through the skin and 
inject the solution very slowly, at the same time, with the pulp of the fingers, press over the 
tract of the injected liquid, and diffuse it as widely as possible through the subcutaneous cel- 
lular tissue, then withdraw the needle gradually. 

Dardenne, of Mauritius, employs the following formula for hypodermic injections: 

Grammes. 

^ Acid bromhydrate of quinine 1 . 

Dilute sulphuric acid gtt. x. . 

Distilled water 10. 

M. 

Or the following solution: 

Grammes. 

]$ Acid bromhydrate of quinine 1 . 00 

Tartaric acid 0.50 

Distilled water 10.00 

M. 



ON THE TREATMENT OF INTERMITTENT FEVER. 437 

respiratory passages, Jousset of Bellesme, has practiced intra-tracheal injections 
of salts of quinine in cases of pernicious fever, and this bold attempt has been 
crowned with complete success. In a previous chapter I have enumerated 
these facts and dwelt on the utility of these intra-tracheal injections. I see 
with pleasure that since the publication of this chapter, the method has won 
favor: Bergeron has maintained its advantages, and in veterinary practice, 
where the trachea can be so easily reached, I have seen Cagny and Levi, of 
Pisa, employ these injections with brilliant success. I believe, then, that in 
cases of pernicious fever it would be well to always have in mind the possibi- 
lity of these tracheal injections of the salts of quinine, and not to hesitate to 
practice them. 

I have finished with the modes of administration of the salts of quinine, 
but before going farther it is well to ask if the introduction of these salts into 
the economy, apart from the symptoms of local irritation which I have pointed 
out, has not other inconveniences. You all know that the principal property 
of quinine salts is to determine a cerebral state known under the name of 
quinine intoxication; but these salts have also been accused of provoking abor- 
tion and hematuria. 

I will say little about the symptoms which constitute quinine intoxication; 
the buzzings of the ears, the vertigo, the obscurations of sight, which are the 
principal symptoms, and which manifest themselves whenever enormous doses 
are given. Women seem more susceptible than men to this physiological 
effect, owing to the predominance of the nervous system in females. So great 
is the susceptibility in some persons that it takes but small doses of quinine 
to produce these symptoms, and it is difficult in such patients to obtain a 
therapeutic effect. It may, in fact, be necessary to abandon quinine and em- 
ploy some other alkaloid of cinchona, cinchonidia, for example, which, in pretty 
large doses, does not occasion any cerebral trouble. 

The question of the influence of quinine in producing hsematuria 5 has 

These injections determine no local accident, except a slight induration. This treat- 
ment has given excellent results with marsh fevers of the island of Mauritius. 

Auliffe's formula is as follows: 

Grammes. 

1$ Bromhydrate of quinine 2 . 

Sulphuric ether, 8 cent. cub. 

Rectified spirits 2 . 

M. A hypodermic syringe full of the above contains io centigrammes of bromhy- 
drate. It is proper to inject as much as a gramme of the salt in cases of pernicious fever. (a) 

5 Antoniades, of Athens, was the first, in 1858, to call attention to the haematuria 
which often follows intermittent fevers. Berettas, the same year, attributed these hsematurias 
to the use of quinine. Karamitzas, of Athens, while admitting that there are intermittent 



(a) Gubler, Note sur l'emploi therapeutique du bromhydrate de quinine (Jour, de thdr., No. 13). — Soulez. 
De Futility du bromhydrate de quinine dans le traitement des fievres palustres (Jour, de ther,, Nos. 21, 24, 
1879). Remarques sur les precautions a prendre pour eviter les accidents locaux de injections hypodermiques 
de sulfate de quinine (Jour, de theY., No. 17. 1876).— Dardenne, Contribution a l'etude du bromhydrate de 
quinine dansles fievres d'orlgine paludeenne (Jour, de ther., No. 9, 1877).— Mac Auliffe, Injections etheYe"es de 
bromhydrate de quinine (Jour, de ther., No. 21, november, 1880). 



438 ON THE TREATMENT OF INTERMITTENT FEVER. 

been especially agitated by Greek and Italian physicians, and we see Ughetti 
and Tomaselli maintain that in many cases hematuria with bilious fever re- 
sults from treatment by sulphate of quinine. It is not, indeed, a veritable 
haematuria which is observed in these cases, but rather, as Karamitzas has 
shown, a hemoglobinuria, that is to say, that the coloring matter of the blood 
alone passes out in the urine. For my part, I have little belief in this quinine 
hematuria, for in typhoid fever treated by large doses of sulphate of quinine, 
you never see hematuria or haemoglobinuria; it is probable then that the 
malarial condition favors the appearance of these hemorrhages At the same 
time, I am of opinion that in individuals affected with hematuria or haemoglobi- 
nuria, it is well to be chary in the use of sulphate of quinine. 

The same reserve should be made when you have to treat pregnant 
women, 6 affected with intermittent fever. Although the action of sulphate of 
quinine on the uterine contractions is still a matter of dispute, and to the facts 
of Monteverdi of Duboue and Warren, who report cases of abortion following 
large doses of quinine in this disease, we may oppose the observations quite as 
positive of Thezet, Delmas, Burdel, and D'Alamo, who have shown that preg- 
nant women may with impunity support quinine treatment — it none the 
less remains demonstrated that in other circumstances quinine may determine 



haematuric fevers, has shown by precise experiments that quinine does determine hema- 
turia, but that in these cases it is not a true haematuria, but rather what he calls haemospheri- 
nuria, in which only the coloring matter of the blood is found in the urine, and not the 
globules. 

Moreover, Ughetti and Tomaselli have maintained that the bilious haematuria, which 
sometimes attends malarial fevers, does not result from the marsh poison, but from the 
toxic action of sulphate of quinine in therapeutic doses. (a) 

6 Quinine has long been considered as a congestioning medicament of the uterus, and 
Tilt and Delioux de Savignac range it among the emmenagogues. It has, moreover, been 
asserted that it may determine uterine contractions and provoke abortion. Thus it is that 
Petijean, Monteverdi, Duboue, of Paris, and Warren, have mentioned cases of abortion 
caused by sulphate of quinine. Thus, too, Cocheran, John Lewis, and Rich consider it a 
useful medicine in obstetrics to quicken the contractions of the womb. To these positive 
facts Thizet, Delmas, Alamo, Bardel, etc., have opposed another series of observations, 
showing that medication by quinine has no danger whatever to the majority of pregnant 
women. Plantard has collected a great number of cases of pregnancy where treatment by sul- 
phate of quinine was followed by no bad results. Nevertheless, as abortion may super- 
vene, it is well to employ at the same time as the quinine, calmative medicaments, and par- 
ticularly subcutaneous injections of morphia and sulphate of atropine. 

Quite recently, moreover, this oxytoxic action of quinine has been affirmed by Larti- 
gan.(^) 



(a) Ughetti, Intoscicazione Chinica e la febbre biliosa ematurica (lo Sperim., fasc 6, 1878).— Karamitzas, 
Sur l'h^maturic provoquee par la quinine (Bull, de theY., t. XCVII, p. 53, 1879). 

(3) Plantard, De l'emploi du sulfate de quinine pendant a grossesse (thee de Paris, 1875). — Duboue" (de 
Pau), De l'action des sels de quinine sur l'uterus (Ann. de gynecol., octobre 1874, p. 286). — Delioux de 
Savignac, Medicaments obstetricaux (Bull, de ther.. t, LXXXL, p. 298).— Tilt, the Lancet, Feb. 1854, et 
Bull, de ther., 1851, t. XL.— Monteverdi, Un. meU, 1871 et 1872.— Thezet, Bull, de ther,, 1846, t. XXX.— Rich, 
Charleston Med. Jour, and Rev., March 1881, et Bull de then, 1892, t. LXII., p. 180.— Lartigan, the British 
Med. Journ., 2 June 1883. 



ON THE TREATMENT OF INTERMITTENT FEVER. 439 

abortion, and you should always have this in mind when you have to treat 
patients in a state of pregnancy. 

To point out the principal alkaloids of cinchona bark and show you the 
superiority of quinine, to indicate the modes of administration and prepara- 
tion, all this does not suffice to make known in their entirety the numerous 
medications which have been counselled in the treatment of intermittent fever, 
and I must now point out the succedanea of cinchona and its derivatives. You 
already know that the principal motive of researches made to find a substitute 
for quinine is the high price of the latter; you will not then be astonished at 
the numerous medicines which have been proposed to take its place, all of 
which have been proved to be inferior to cinchona. These succedanea have 
been derived successively from the vegetable kingdom, from the mineral, and 
even from the animal kingdom, and without giving you a complete list of these 
medicaments, I will only point out the principal of them. 

I shall omit mention of the indigenous plants which have been recom- 
mended in intermittent fever, 1 making allusion only to berberis vulgaris so 
much praised by Piorry, centaury recently experimented with by Bertin, euca- 

1 The barberry (berberis vulgaris) contains in the bark of the root, which is very bitter, 
two alkaloids: berberine and oxyacanthine; the last is one of the most bitter of substances. 
An extract has been made from the bark of the root which has been counselled in malarial 
fevers, and oxyacanthine has been used instead of quinine. 

The European centaury (centaurea calcitrapa), which grows everywhere in chalky soils, 
has been employed by Bertin under the form of alcoholic extract of the root, in intermittent 
fevers. In the Quotidian form, it suffices to give during two or three days, six pills of three 
grains each, one pill every two hours, to break up the attack. In the grave forms it is neces- 
ary to exceed the quantity of fifteen grains a day. The same medicament is valuable in the 
larvated fevers. (Bertin, on the Employment of Centaury in Malarial Fevers, Montpellier 
Medical Journal, February and March, 1876). 

Under the name of cedron nuts there exist two products of different origin. The one 
belongs to the simaba cedron, or quassia cedron; the other to the valdivia (picrolemma valdi- 
via). The first of these fruits contains a product known as cedrine, which is uncrystallizable 
and which is injected under the skin in doses of -£$ to yg- of a grain. In Columbia the cedron 
powder is used, mixed with a little brandy, in the dose of eight to fifteen grains a day. This 
powder of cedron has been used by the Indians from time immemorial. 

In 1848, Vauvert, of Mean, vice-Consul of France, at Panama, sent a box of cedron 
nuts to the Academy of Medicine, but no trials were made; in 1852, however, Reyer demon- 
strated the febrifuge properties of cedron. Purple, of New York, Posada Arango, of Colum- 
bia, employed also with success in malarial fever the powder of cedron nuts. Dujardin- 
Beaumetz and Restrepo have also obtained good results by this means, while Bardel reports 
only disappointments. 

The fruit of Valdivia contains an alkaloid, discovered by Tanret, and crystallized under 
the name of valdivine, and which has for formula: 

C36H3402 5 HO. 

This valdivine is eminently toxic; -^ grain killed a hare in eighteen hours; it deter- 
mines vomiting in man in the dose of T X F grain. In cases of hydrophobia, valdivine causes 
abatement of the convulsive paroxysm, without, however, accomplishing a cure, (a) 



(a) Restrepo, a Study of Cedron, of Valdivia, and their active principles, Paris, 



440 ON THE TREATMENT OF INTERMITTENT FEVER. 

lyptus which Gubler and Gimbert introduced into therapeutics, and lastly, 
cedron, which I have studied along with my pupil, Restrepo. 

This experimental investigation showed us, first, that there exist two kinds 
of cedron; the one belonging to the simaba cedron, the other to a variety of 
plant whose botanical characteristics Planchon, our colleague at the Academy, 
has determined, viz: the picrolemma valdivia. From the first a neutral non- 
crystallizable substance has been obtained called cedrine, from the other a 
crystallizable alkaloid, discovered by Tanret, viz: valdivine. Cedrine alone has 
an action in intermittent fever, in the dose of four milligrammes (y 1 ^ grain) in 
subcutaneous injections, or under the form of cedron powder as the Indians of 
Columbia prepare it, and which is given in the dose of one-half gramme to one 
gramme a day (y% to 15 grains). The trials which Restrepo has made in Sol- 
ogne with cedron and cedrine, while showing us the febrifuge properties of this 
substance, have also proved its inferiority to the salts of quinine. 

Eucalyptus has enjoyed a much greater reputation, and it was thought that 
we had found a real substitute for cinchona, having this singular advantage that 
the cultivation of this tree, so strange in color and in the shape of its leaves, 
has the power to destroy the marsh miasm. 1 Hence it is that you may see in 
the Campagne Romaine the railroad stations in the most unhealthy localities, 
surrounded with eucalyptus trees. But more rigorous observation of the facts 
has shown that the preparations of eucalyptus are untrustworthy medicaments 



1 The eucalyptus globulus is a' tree of the Myrtaceae family, which often attains a 
colossal size. All the parts of the tree and especially the leaves contain an aromatic essence, 
eucalyptol, which has been analyzed by Cloez. 

This tree was introduced into France in 1857 and 1858 by Ramel. It is to-day culti- 
vated in abundance in the Maritime Alps, and in Algeria. 

Gubler and Gimbert have studied the physiological action of eucalyptol. It produces 
excitation in the dose of several drops, and irritation, if the dose is augmented from half a 
drachm to a drachm. 

This tree, which is called fever tree, has been employed from the earliest time by the 
Aborigines of Australia in the treatment of intermittent fever. More than forty years ago 
the captain. of a schooner from Salvy saw the good effects of the bark and leaves in an epi- 
demic of pernicious fever which broke out among the sailors of the French sloop, La Favorite, 
at Botany Bay. In Corsica, Regulus Carlotti, of Ajaccio, obtained remarkable results from 
eucalyptus in the treatment of paludal fevers, and he had similar success in Algeria. 

In these cases the tincture of the leaves or the powder is generally used. Gubler gave 
of this powder from sixty to ninety grains a day. Kirchberg treated nineteen patients by 
eucalyptus, and all got well without sulphate of quinine. Burdel, of Vierzon, has obtained 
only incomplete results in the treatment of the malarial fevers of Sologne. 

Eucalyptus has still another property, that of destroying on the spot the marsh miasm, 
and this results either from the rapid absorption of the water by this tree (which is very 
greedy of water), or from the aromatic emanations which it develops, (a) 



(a) Gubler, l'Eucalyptus et son emploi en th6r, [Bull, de the>., 1881, t. LXXXI, p. 145].— Castan, Mont- 
pellier m£d., 1872, t. XXX, n° 6.— Burdel [de Vierzon], l'Eucalyptus globulus en Sologne [Bull, de theV., t. 
LXXXV, p. 529].— Gimbert [deGannes], l'Eucalyptus globulus, 1870, p. 69.— J. Campian, l'Eucalyptus globu- 
lus et l'Eucalyptol [these de Paris, 1872].— Re"gulus Carlotti, Memoire sur Taction therapeutique et la composi- 
tion elementaire de l'ecorce et de la feuille de l'eucalyptus, presents' a la Society d'agriculture d'Alger, 1869 — 
Kirchberger, Observations de fievres intermittentes traite's au moyen de l'eucalyptus globulus [Journ. de m^d. 
de l'Ouest, ire se"rie, 6e annde, t. VI, p. 260]. 



ON THE TREATMENT OF INTERMITTENT FEVER. 441 

in the treatment of intermittent fevers, and that it will not do to depend on the 
cultivation of this tree to effect the disappearance of malaria. 

I will say nothing of jaborandi or pilocarpine. 1 Rokitanski and Griswald 
have indeed recommended this alkaloid in the first period of intermittent fever, 
but this is an exceptional kind of treatment which is not applicable to the par- 
oxysmal stages of the fever as ordinarily witnessed. 

Among the substances not of vegetable origin 2 which have been recom- 
mended in the treatment of fever and ague, I will enumerate only picric acid 
and the picrates, arsenic and the arseniates and the medicaments of the aro- 
matic series. 

A dozen years ago, I made some researches on the physiological action of 
picrate or carbazotate of ammonia, and, while recognizing that this medicament 
diminished the number of pulsations and produced on the part of the brain a 
symptomatic aggregate comparable to quinine intoxication, I noted, after Bra- 
connot, Calvert and Mossa, Haspland, Parisel, 3 etc., its febrifuge action; only 
this action, like that of the succedanea of quinine generally, is uncertain. 

1 Griswald counsels in intermittent fevers subcutaneous injections of one-sixth grain 
of pilocarpine. These injections, according to him, not only cause the chill to subside, but 
they often throttle the paroxysm, and when one or two attacks have been cut short the fever 
does not return. He advises the employment of these injections in pernicious fever, (a) 

2 Certain mineral substances have been recommended in intermittent fever, such as 
chlorate of potassium (febrifuge salt of Sylvius; chloride of sodium, vaunted by Thomas, of 
Nesv Orleans, Selles, of Mount Desert, and Piorry; chloride of ammonium, extolled by J. 
Franck, Aran, and Padiolo; tincture of iodine (Seguin, Boinet, and Barilleau, of Poitier); 
solution of iodide of potassium (Wildebrand and Helsingfors); the sulphites and hyposul- 
phites, by Polli. 

3 Picric or carbazotic acid was discovered in 1788 by Hanssmann. Obtained in 1794 
by Welter, by the action of nitric acid on silk, it was prepared in 1834, by Runge, by expos- 
ing tar oil to nitric acid. Laurent in 1841 showed that this substance was a derivative of 
phenic acid [C 12 H 5 0,HO], in which three molecules of NO 3 are substituted for three atoms 
of hydrogen; it is called on this account trinitrophenic acid. Certain alkaline carbozotates 
are very explosive, but the carbazotate of ammonia is not so. It crystallizes in brilliant 
yellow rectangular plates or six-sided prisms, and is of an intensely bitter taste. 

It was Braconnet, of Nancy, who first, in 1830, employed the picrate of potassa as a 
febrifuge. Calvert and Massa, in 1836, pointed out the antiperiodic properties of picrate of 
ammonia. In 1862 Aspland again took up the subject and showed that one could derive the 
same effects from carbazotate of ammonia as from sulphate of quinine in the treatment of 
the malarial fevers of the Indias. 

Parisel, in 1S68, quotes the reports of Barot (Son), who obtained a cure in more than 
sixty cases of fever and ague by frequent three-grain doses of picrate of ammonia. The 
same success was obtained by Henry, of Tureaux, in the province of Cher, by Chazereau, at 
Aubigny, by Charles Fiain, at Sancerre, and Manoha, at Medeah. 

Dujardin-Beaumetz has studied the physiological and therapeutical action of carbazotate 
of ammonia. This salt causes diminution in the beatings of the heart, and in the dose of 
one grain brings down the pulse ten beats. In the frog there is produced arrest of the heart 
with one-sixth grain; in the hare three grains diminish by one-half the pulsations of the heart. 
When you exceed one grain or a grain and a half a day, you produce a train of symptoms 



(a) Griswald, Pilocarpine in Intermittent Fever [New York Med. Jour., August, 



442 ON THE TREATMENT OF INTERMITTENT FEVER. 

Boudin has given us the most precise directions, how to treat intermittent 
fever by arsenic. 4 - 6 Everybody is agreed in acknowledging the great service 
which arsenical preparations render, not so much in the treatment of the mor- 
bid periodicity, where they are proven to be very inferior to quinine, as in the 
malarial cachexy, where arsenic is superior to cinchona and its derivatives. The 
arsenical medication cannot then take the place of cinchona, but it is the ad- 
mirable complement of the latter. 

The powerful antiseptic and anti-thermic effects of medicaments derived 
from the aromatic series have also been applied to the treatment of the paludal 
fevers, and in the case of certain of them this action was one of the first thera- 



which Parisel described under the name of picric poisoning, very similar to quinine poison- 
ing, and characterized by headache, vertigo and general enfeeblement. Dujardin-Beaumetz 
administers carbazotate of ammonia in pills containing one-sixth grain. He gives five or six 
of these pills a day. This medicament acts well in intermittent fevers, but its action is un- 
trustworthy and inferior to that of quinine, (a) 

4 - 5 It is to Boudin that we are indebted for the best directions for the treatment of in- 
termittent fever by arsenic. Nevertheless at the beginning of the seventeenth century Had- 
rien, Slevogt and Melchior Frick definitely established the antiperiodic and febrifuge 
properties of arsenic. Plencitz senior, and Slevogt made great use of arsenious acid, and 
affirmed almost constant success in the treatment of malarial fever. The latter was in the 
habit of giving from one-half to one grain daily. Boudin has gone so far as to give three 
grains a day. Millet has never exceeded two-thirds of a grain; Sistache begins by doses of 
one-half grain. Boudin's solution is as follows: 

3 Acid arsenions, i part. 

Water, 1,000 parts. 

Mix. 

Delioux, of Savignac, has reduced the formula of arsenious acid to fifty centigrammes 
to the litre (iooo grammes) and each dose of a tablespoonful represents one centigramme (or 
one-sixth of a grain) of arsenious acid. 

Sistache employs a solution containing five centigrammes (five-sixths of a grain) of 
arsenious acid to fifty grammes of water, i. e., one centigramme to every ten grammes. Out 
of 229 patients affected with intermittent fever, treated with arsenious acid, Sistache has 
never had a failure. He affirms that arsenious acid is as efficacious as quinine, but that it 
acts more slowly. Also in pernicious fever it is completely inefficacious. 

Delioux, of Savignac, prefers arsenic to quinine in the treatment of periodic neuralgias. 

Moutard Martin considers the arsenical medication as superior to every other in the 
treatment of paludal cachexia. Hydrotherapy alone can be compared with it. 

During the last few years, Mosler has proposed a different medication for impaludism 
with induration of the spleen. He injects directly into the parenchyma of the organ, from 
ten to twenty drops of Fowler's solution, following each injection by applications of ice. 

[From Fowler's summary of his own experience, it appears that 171 out of 247 cases of 
ague were radically cured by the arsenical solution which bears his name. The cures gen- 
erally took place within four days from the time when the administration of the medicine 
was commenced. Withering cured thirty-three patients out of forty-eight by the solution 



(a) Braconnot, Ann. de phys. et de chim., t. XLIV, p. 297.— Aspland, Med. Times, 1862.— Parisel, Action 
physiol. et ih6r. de l'acide picrique (these de Paris, 1868).^— Dujardin-Beaumetz, De l'emploi du carbazotate 
d'ammoniaque comme succedane" du sulfate de quinine (Soc. de ther., juillet 1872, et Gaz. med. de Paris, 1872, 
Nos. 37, 38 et 39). Nouveaux faits relatifs a l'emploi du carbazotate d'ammoniaque (picrate d'ammoniaque) 
comme succedane du sulfate de quinine (Bull. g6n de the"r., 1872, t. LXXX, p. 385). 



ON THE TREATMENT OF INTERMITTENT FEVER. 443 

peutic effects observed; thus, for instance, when salicin was first extracted from 
willow bark, it was considered a succedaneum of quinine. Since salicylic acid 
has been obtained by way of synthesis, this acid and salicylate of soda have also 
been applied to the treatment of fever and ague. 6 But it must be admitted 
that these medicines have been but little efficacious in the treatment of febrile 
intermittence; therefore, notwithstanding the results obtained by Bartels and 
by Zielewicz, this mode of treatment has not come into use. 

I may say as much of resorcin, and, although Kahler and Lichtheim have 
maintained that this medicament is equal and even superior in rapidity of action 
to quinine, I have never obtained such an effect in the trials which I have made 
of it. 7 As for quinoleine, which is now obtained from the phenols and oxyphenols, 

alone; in the remaining fifteen cases it failed entirely. Willan prescribed it in about fifty 
cases of different species of intermittents, and it succeeded almost instantly in every case. 
It was found by Winterbottom to be equally successful in the African intermittents at Sierra 
Leone. 

In Philadelphia it was early employed by Wistar, Griffiths, Barton and Currie; the last 
named of whom mentions that it was a common practice in the State of Delaware to give 
the Asiatic pills, composed of arsenic and black pepper, for the cure of agues. In 1820 Dr. 
T. D. Mitchell found it more effectual than bark during an epidemic at Norristown, Pennsyl- 
vania; but unless he gave Fowler's solution in doses of fifteen or twenty drops, his patients 
derived no benefit from its use. Eberle was of opinion that it was best suited to the disease 
in persons of a firm and healthy constitution, and most apt to act injuriously when given in 
a debilitated, cachectic and irritable state of the system. In England, as late as 1833 we find 
Dr. Joseph Brown stating that he had given the arsenical solution in many hundreds of 
cases, without witnessing any permanently ill-effects produced by it, and he states that he 
has met with cases which were cured by arsenic where quinine had failed. 

Extensive trials have been made with this medicine in intermittent fevers in this and 
foreign lands the past forty years, and it must be confessed, without establishing its superi- 
ority over the cinchona preparations in any form of malarial affections, unless it be certain 
chronic forms which have resisted quinine. 

The rules for the administration of Fowler's solution in intermittent fevers are as fol- 
lows: Children of from two to five years of age to take one-half drop at a dose for each 
year; between the ages of eight and twelve years, the dose should be from two to four drops. 
Beyond this age, three to five drops should be given three times a day for five days, then 
suspended for two or three days and again resumed to prevent a relapse. (Stille, Materia 
Medica and Therapeutics, Art. Arsenic). — Trans.] (a) 

6 Bartels considers salicylate of soda as an excellent medicament in intermittent 
fever. Zielewicz is of the same opinion, and gives the salicylate during the paroxysm to 
prevent a second attack; he admits, however the inferiority of this medicament to qui- 
nine, than which it is far less certain. 

7 Resorcin has been given in intermittent fevers by Lichtheim and by O. Kahler, 
in the dose of one-half drachm to a drachm at the onset of the attack. This dose 



{a) Delioux de Savignac, Examen compare des proprietes febrifuges du quinquina et de l'arsenic [.Bull, 
de ther., 1853, t. XLV, p. 294, 295). — Sistache, Emploi therapeutique de l'arsenic [Gaz. med., 1861, p. 67]. — A 
Millet [de Toursl, De l'emploi therapeutique des preparations arsenicales, Paris. 2e edit., 1865]. — Boudin, Traite - 
des fievres intermittentes et contagieuses des contrees paludeennes suivi de recherches sur l'emploi therapeu- 
tique des preparations arsenicales, Paris, 1852. — Fremy, De la medication arsenicale dans les fievres intermit- 
tentes, Paris, 1857. — Moutard-Martin, Medication arsenicale dans le traitement des fievres paludeennes [Acad, 
de med., 1872]. — Mosler, Uebr Parenchymatose injection von solution arsenicales Fowled inchronische Mitztu- 
moren [Deutt. Med. Woch., n° 47, 1880]. 



444 ON THE TREATMENT OF INTERMITTENT FEVER. 

I have already alluded to it while speaking about the derivatives of cin- 
chona, and I do not know that kairin, which has since been similarly obtained, 
has given any positive results. 

There are several succedanea of quinine derived from the animal kingdom, 
such as oyster shells and cuttle-fish bones, formerly vaunted by Brault and 
Peneau, and especially spider's web, a popular old remedy of which Oliver has 
lately shown the real efficacy. 8 Despite the affirmations of these men I believe 
that the sulphate of quinine is still preferable and that in many cases nothing 
will take its place. 

It remains for me now, having finished the enumeration of medicaments, 
to tell you how to use them to obtain as speedily and economically as possible the 
cure of intermittent fever. I emphasize the word economically, for this is an 
important matter. Do not forget that sulphate of quinine is to-day sold in our 
drug stores at a medium price of i-J francs (or about 30 cents) a gramme. 
In regions, moreover, where the marsh miasm is prevalent you are apt to find 
an indigent population, and it will always be incumbent on you to effect the 
desired therapeutical results with minimum quantities of quinine, that is to 
say, with the least possible expense. 

We ought from the point of view of the treatment of intermittent fever, to 



markedly attenuates the symptoms, sometimes even causing their subsidence and cessa- 
tion. Its action is immediate, as all observers testify, so that it may be given in the 
midst of an attack. It also lessens the volume of the spleen, and hence ought to be 
mentioned in the same rank as quinine. Dujardin-Beaumetz and Callais, in their researches 
on the action of resorcin in intermittent fevers, have obtained but meagre results; it is 
true that they gave much less doses than the above, and never exceeded fifteen grains. 
Perraton has also obtained uncertain and temporary results from resorcin in the treat- 
ment of malarial fevers, (a) 

8 Spider's webs have been used from time immemorial. In 1809 we read of a French 
curate who treated intermittent fevers by making patients swallow little balls ot spider's 
web. 

Dr. Oliver has again taken up the subject, and has made over ninety-three trials 
with pills made of spider's web. His conclusions are as follows: 

r. Spider's web may cure malarial fevers of quotidian and tertian type; 

2. The dose for an adult is thirty grains. For children a proportionately smaller 
dose; 

3. Its effect is not so prompt as that of quinine; hence it should not be relied on 
in grave cases; 

4. Spider's web has a better taste than quinine; 

5. Relapses are less frequent than with quinine. 

Brault and Peneau have also counselled the bones of cuttle fish and oyster shells 
in malaria, (3) 



(a) Dujardin-Beaumetz and Callias, on Resorcin and Its Employ in Therapeutics, Paris, 1881— Perraton, 
on the Employment of Resorcin, [these de Paris, 1882). 

{b) Corre, Sur la toile d'araign^e dans le traitement des fievres intermittentes [Bull, de then, 1883, t. CV, 
p. 331, et Tres. des men., Paris, 1828].— Oliver, Toile d'araignee contre la malaria LAllgem Wiem. Med. Zeit. 
10 aoril 1883, et Zeits. d. A. o. Apoth. Vereins, avril 1883]. — Brault et Peneau, De la gnerison des fievres inter- 
mittentes et larveesau moyen de l'os de seiche et de l'ecaille d'huitre, 1864. 



ON THE TREATMENT OF INTERMITTENT FEVER. 445 

examine the three following points, and in their order: treatment of ordinary 
intermittent fever, treatment of pernicious fever (malignant intermittent), treat- 
ment of the paludal cachexia. Finally, we shall finish by a rapid examination 
of the hygienic conditions which one should recommend to prevent the devel- 
opment of intermittent fever. 

As for the treatment of ordinary intermittent fever, we should place our- 
selves in two special conditions: either the individual resides at a distance from 
the marshy locality, or he is still exposed by his residence to the marsh miasm. 
In the former case by the sole fact of his removal to a more healthy region he 
may get well; this it is that explains how in our hospitals at Paris we are in such 
an unfavorable position to study the anti-periodic action of certain medicines. 
For generally the intermittent fever which we observe is light, and consists of 
relapses in individuals who have formerly contracted malaria in other countries. 
Therefore we cannot rely altogether on trials made in the hospitals of Paris, in 
deciding the febrifuge virtues of this or that medicine, and it is in regions where 
this fever reigns that such essays should always be made. In Paris then you 
can witness the disappearance of intermittent fever under the influence of re- 
pose, a simple emetic, or a small dose of quinine. 

When your patient resides in the country where the «,marsh miasm is devel- 
oped, your treatment will be more difficult, and you will have to study succes- 
sively what preparation to use, at what moment to give it, and the proper 
dose. 

As for the choice of the preparation, you had better discard all the pre- 
tended succedanea of quinine, also the powdered peruvian bark and the vari- 
ous old remedies that contain it, 1 the extracts of cinchona as well, 2 not because 



1 The bolus ad quartemam had the following formula : 

Grammes. 

IJ Pulv. cinchona, 30 

Tartar emetic, 

Carb. pot., 4 

Syrup papaver, q. s. 

M. Make up into 60 boluses; all to be taken during the 24 hours. 

The Remede du Calvaire is similar to the above; its formula is as follows: 

Grammes. 

^ Yellow calisaya bark [pulv.] , 40 I 

Tartrate of antimony, | 05 

Rhubarb, ) .... , 

Carb. pot , f aa "' 4 I 

Syrup of cinchona, q. s. 

M. F. S. A. bol, No. x. Sig. One bolus morning and evening. 

2 The extracts of cinchona are very numerous; they are all acid, and present, accord- 
ing to the bark which has furnished them, a very variable composition. Tanret has given 
a table indicating for each gramme of the divers extracts the quantity of alkaloids and 
tannin contained, as well as the acidity, represented in lactic acid. According to this 
table, the Java bark is richest in alkaloids, each gramme having 0.157 of active principles, 
while the Loxa is among the poorest, each gramme representing only 0.014 °f the alka- 
loids. The cinchona calisaya is an excellent bark, with the decimal figure, representing 
richness in alkaloids, of 0.115. Some of the red cinchonas are poor in alkaloids, but rich 
in tannin; the proportion of the latter varies in them all from 0.050 grm. to 0.210, grm. a 



446 



ON THE TREATMENT OF INTERMITTENT FEVER. 



they are inert but because they are more beneficial in the chronic form of marsh 
poisoning than in intermittent fever. You should reject all the other alkaloids 
of cinchona and rely on quinine alone, whose effects can be determined with 
almost scientific precision. 

You should prescribe either the sulphate or the hydrochlorate of quinine, 
and I cannot too strongly urge you, breaking the bonds of tradition which has 
given the preference to the sulphate, to use the chlorhydrate instead, a salt more 
soluble, more rich in quinine, and for that reason more active. In adjoining 
countries this substitute is an accomplished fact, and we should not be behind 
them in this regard. 

You will administer the chlorhydrate of quinine in solution when your pa- 
tient is poor, in capsules when he is rich, and you will understand the reason 
for this; the capsules as I have before told you, are a little less active than the 
solution; as for the latter the simplest and most economical way consists in 



quantity contained per gramme in some of the red barks, 
part: 



We give below the table in 



SPECIES OF CINCHONA. 



TANNIN. 



ALKALOIDS. 



ACIDITY IN LAC- 
TIC ACID. 



Cinchona huanuco, 

Cinchona Loxa, 

Cinchona flava [without any other denomina 
tion] 

Java cinchona, 

Cinchona calisaya, 

Indian cinchona, 



0.065 grammes, 
0.014 " 

O.OIO 4< 

0.157 

0.115 
0.065 " 



0.050 grammes. 
0.176 " 

0.062 " 
0.030 " 
0.047 
0.050 



0.054 grammes. 
0.047 

0.050 
0.074 

0.063 " 
0.070 " 



Tanret has proposed to substitute tannate of quinine for the soft extracts, and would 
replace the potions made with soft extracts [so fashionable in France] by the following 
formula, which has the advantage of being always of uniform strength: 

5 Tannate of quinine, As many times 23 centi- 
grammes as you would 
have put grammes of 
the extract. 

Acid lactic, q. s. to dissolve. 

Syrup, 30 grammes. 

Water, 120 grammes. 

Mix and dissolve. 

Quinium is a complete extract of cinchona, obtained by alcohol and lime. This qui- 
nium represents 33 per cent of its weight of quinine, plus all the other active principles 
of cinchona. The formula of its preparation is given by Delondre and Labarraque. 
[It is a popular cinch onic preparation.] (a) 



(a) Tanret, study of the extracts of cinchonia (Bull, de Then, 1883, t. 105, p. 65). 



ON THE TREATMENT OF INTERMITTENT FEVER. 447 

causing your patient to take his quinine in a small glass of rum or brandy. 
But what shall be your dose, and when shall it be given? I will explain. 

You know that the attack of intermittent fever is characterized by periods 
or stages, which are described under the names of period of chill, period of 
heat, period of sweating; that moreover, according as the fever returns every 
day, every two days, or every three days, you have to do with the fever in a 
quotidian, tertian, or quartan form. You know also, that these types may be 
double, and then you have double tertian and double quartan. I shall not 
dwell on this point, but pass at once to the consideration of the first question: 
at what period should you give the sulphate of quinine to derive the most ad- 
vantage from it ? 

Practitioners have long hesitated between three methods; 1 that of Torti 
called the Roman method, that of Sydenham, called the English method, and 
that of Bretonneau, called the French method. According to Torti's method, 
you would give the quinine at the moment of paroxysm, not to arrest it, but to 

1 In the treatment of fever and ague, cinchona was administered according to three 
different methods: 

i. The Roman method, indicated by the Jesuit fathers, and adopted by Torti. 

2. The English, or Sydenham's method. 

3. The French, or Bretonneau's method. 

According to Torti's method, the cinchona is given in one dose, immediately after the 
attack. First fifteen grains, in one dose; then, two days after, a dose of sixty grains, and 
after an interval of eight days of rest, a thirty grain dose was administered. 

According to Sydenham's plan, the cinchona was given after the attack, but in 
fractional doses in the interval of the attacks (half dram to dram doses every two hours, 
till from half an ounce to an ounce was taken). Sydenham prescribed the cinchona in 
the form of an electury, in pills or in wine. He used to put an ounce of powdered 
Peruvian bark into two quarts of wine, and direct the patient to shake it and drink eight 
or nine teaspoonfuls every four hours. Morton, Stoll, and Van Swieten adopted Sydenham's 
method. Cullen rejected it, and returned to the Roman method, somewhat modified; the 
cinchona was taken in small doses repeated every hour, and administered, not after, but 
before the paroxysm. 

The method of Bretonneau consisted in giving two drachms of powdered yellow 
Peruvian bark, or fifteen grains of sulphate of quinine, in one dose or two doses, near 
together, immediately after the paroxysm. After five days of rest, the same dose was 
repeated, then after an interval of eight days, and so on, every eight days for a month. 
Trousseau, a pupil of Bretonneau, used to give two drachms of yellow calisaya bark in 
powder (or fifteen grains of quinine) in a couple of doses, one hour apart. He let the pa- 
tient rest a day, and then gave the medicine in the same way the third day, generally in two 
doses, one right after the other. Then he allowed three days of interval, then four, six, 
seven, and eight, and for a month or two returned every eight days to the same treatment, 
never diminishing the dose. The medicament was always given at meal time. 

Briquet has made a series of experiments to ascertain the best time to give sulphate of 
quinine, and these are his conclusions: 

1. A dose of 4 to 6 grains of sulphate of quinine suitably administered, is sufficient to 
cut short any attack of simple intermittent fever in the climate of Paris, and in all other 
places not paludal. 

2. When there is an interval of but a few hours in which to administer the febrifuge 
before the time of paroxysm, one may still hope to arrest the next attack. 

3. If you have only 12 hours before the regular attack, you have almost a certainty of 



448 ON THE TREATMENT OF INTERMITTENT FEVER. 

prevent the following ague fit. Sydenham gave his Peruvian bark in one large 
dose after the attack, and in smaller doses in the interval. Bretonneau and 
Trousseau followed the method of Sydenham, but they employed larger doses, 
which they gave immediately after the attack; this is also Briquet's method, 
who would have at least fifteen hours between the giving of the dose and the 
ague fit which he wished to prevent. 

While admitting the views of these three French authorities with regard to 
massive doses, I believe that the space of time which separates the administra- 
tion of the doses from the onset of the attack is too long, and I am of the 
opinion that it is well to give it, not as Torti recommends, at the period of 
chill, but three to four hours before the paroxysm. 

As to the dose, it should be variable according to the intensity of the 
fever, and you can give 50-75 centigrammes or one gram (from seven to fifteen 
grains) of chlor-hydrate or sulphate of quinine. When the fever is tertian, 
which is its most frequent type, you should give your quinine every, other day, 
and note the action of your medicine, which ought to produce retardation and 
diminution in the intensity of the attacks until they completely disappear. 
Even then it is not best to cease the administration of the quinine, but to con- 
tinue it for eight days or so, in smaller doses, a short time before the usual 
return of the paroxysm. All the rules which I have given apply to simple 
intermittent fever, and you should change your mode of treatment when you 
have to do with pernicious fever 2 (called malignant, remittent, or intermittent 
fever) . 

arresting it, but it is. at the same time, not best to leave a shorter interval than 15 hours 
between the administration of the last powder and the paroxysm. 

4. As, finally, the febrifuge action of quinine continues without losing its power for a 
space of two days, at least, one may, if circumstances require, give the quinine that length 
of time before the attack, (a) 

2 Intermittent fevers may be pernicious from the first, or succeed simple attacks; after 
having been attended, for awhile, with the ordinary symptoms, the disease presents sud- 
denly, or gradually, frightful phenomena, which are followed by death unless the disease 
be arrested by some remedial means. 

The varieties of pernicious fever are numerous. We will notice them according to the 
symptomatology — the morbid phenomena accentuating themselves in certain organs and 
functions — as follows: 

1. Pernicious fever, of cerebral form. 

2. Pernicious fever with algid, choleriform, sweating symptoms. 

3. Pernicious fever with cardialgic, dysenteric symptoms. 

4. Pernicious fever of thoracic form. 

1. Pernicious fever of cerebral form is the most frequent. It is characterized by coma, 
delirium, convulsions, paralysis. 

The comatose form is the most common. It is this which is met with oftenest in chil- 
dren. It is characterized by somnolence, lethargy, and finally, coma, which generally 
succeeds the febrile paroxysm. It is rare that death comes on before the third or fourth 
attack. 

The delirious form is characterized by a delirium more or less violent, sometimes 



(<*) Briquet, Therapeutical Treatise on Cinchona and its Alkaloids, p. 500. 



ON THE TREATMENT OF INTERMITTENT FEVER. 449 

This kind of fever, as you are aware, manifests itself by attacks of great 
gravity, and may be fatal in the first, second or third attack; here, then, there 
is no precise therapeutic rule, and as soon as you have diagnosticated the per- 
nicious character of the affection, you may administer your quinine even during 
the paroxysm, in the promptest way possible. 

You know that in light cases Jousset, of Bellesma, does not hesitate to 
have recourse to intra-tracheal injections of quinine, and I am inclined to think 

furious; the agitation is extreme, the skin warm, covered with sweat, the pulse strong and 
vibrating, the pupils dilated, then coma and convulsions set in. You may observe a general 
tetanic rigidity, cataleptic phenomena, epileptiform convulsions, laryngeal spasms (hydro- 
phobic fever), syncopes (syncopal fever). It is quite rare that the delirious forms develop at 
first; ordinarily, they are preceded by regular ague fits, attacks of fever, and violent pain in 
the head. At Senegal, according to Fonssagrives, the comatose form is sometimes observed 
among the fevers which are pernicious from the onset; this form is the most grave. 

The delirious and convulsive form is but the prelude to the comatose fever, to which the 
patient succumbs in an insensibility as complete as apoplexy. When the attack is not fatal, 
the patient, little by little, after 12, 24, or 36 hours, comes to himself, and may regain fair 
health till the next fit. 

A paralytic fever has also been described; this is rare. It is characterized by partial 
paralysis, by hemiplegia, or by paraplegia, as was observed in numerous instances at 
Senegal, by one of our confreres. 

2. Algid and cholen 'form pernicious fever, — This is especially observed in hot climates. 
The algidity may be the first stage of the fever, or it may appear in the second stage. It is 
sometimes during the sweating period that the patient begins to become cold and turns pale. 
He complains of internal heat, demands cold drinks, then all at once he experiences a deadly 
chilliness, his face becomes cadaverous, there is agitation, thirst, the voice is broken, the 
pulse becomes small and precipitate, the skin is covered with a cold clammy sweat, and 
death often comes speedily, the patient remaining in full consciousness; or it may be, in a 
few hours, heat returns little by little, and the patient recovers. 

The choleriform form exists alone, or is linked to the preceding. It is characterized by 
profuse, incoercible diarrhoea, and symptoms resembling those of cholera; suppression of 
urine, choleriform voice and aspect, cramps, vomiting. If a prompt remedy is not forth- 
coming, the patient succumbs to a cholera asphyxia. In the diaphoretic form, which is 
especially frequent in India, the two first stages are normal, or shorter than ordinary. Dur- 
ing the period of sudation the sweats are of an excessive abundance, but become cold; there 
is general cutaneous chilling; the pulse falls; the patient is greatly oppressed; often there is 
suppression of urine; profuse stools, resembling beef washings, which, later, are colorless. 

3. Pernicious fever with cardialgic symptoms. — These symptoms are often observed 
without any previous prodrome. They are characterized by a severe rending pain in the 
epigastrium and heart, generally supervening in the stage of chill, and often accompanied by 
nausea and vomiting, general anguish, coldness in the body and syncope. Death generally 
attends the second attack. 

4. Pe?-nicious fever of thoracic form. — Intermittent pneumonias have been described; 
Grisolle admits the existence of a pleuritic pernicious fever, and especially a pneumonic 
pernicious fever. In the case of intermittent pneumonia, the chill, the fever, the dyspnoea, 
the bloody sputa exist as in ordinary pneumonia, the crepitant rales localized in one side of 
the chest; then with the sweating stage all the symptoms are mitigated, or disappear if there 
be nothing but hyperaemia of the lung, but the stethoscopic signs persist, if the lesion is 
more advanced, only the fever and the subjective symptoms -diminishing. Rarely there are 
true intermittent pneumonias; oftener there are intermittent bronchites or broncho-pneu- 
monias, coinciding with the febrile paroxysm?, and giving rise to cough, dyspnoea, thoracic 
pain, etc. 



450 ON THE TREATMENT OF INTERMITTENT FEVER. 

favorably of this practice; at any rate, we witness here the triumph of subcu- 
taneous injections, and you ought always to resort to them, whether you make 
use of the bromhydrate, the sulpho-vinate, or the lactate. You will require 
large doses, and you ought never to hesitate to give fifteen or twenty grains, 
and even twice as much, increasing your dose according to the urgency of the 
case; there have been cases where as much as 75 grains have been admin- 
istered. 

When the individual has for a long time suffered from attacks of intermit- 
tent fever, and when, moreover, he continues to live in localities infected by 
malaria, grave modifications are often effected in the functions of certain 
viscera. The spleen becomes enormously hypertrophied, the liver is enlarged, 
the blood is profoundly altered, and symptoms supervene whose aggregate con- 
stitutes the malarial cachexia. I shall not here describe this cachexia, but what 
I can assure you is that the alkaloids of cinchona are impotent against it. Here 
you will often witness the triumph of arsenic, and hydro-therapy is of benefit. 1 
This last means is one of the most powerful resolvents in splenic and hepatic 
engorgements, and signal success has been obtained in these cases by douches 
of cold water directed over the spleen or liver. 

Here the tonic medication is indicated under all its forms, but all means of 
this kind are without avail if the individual does not submit to the hygienic 
treatment which enables him under certain circumstances to avoid the toxic 
action of the marsh miasm. This hygienic treatment I shall now explain. 

The measures of prevention are of two kinds; the one on which I shall 
now insist, concerns the drying-up of the marsh itself and its purification, the 
other concerns private hygiene. 2 As for the first, you know that three methods 
have been employed to get rid of stagnant waters, namely, by filling in with 

1 Fourcade is the great advocate of the treatment of intermittent fevers by hydro- 
therapy. It gives, he says, good results where quinine fails, (a) 

2 The reclaiming of marshes and rendering them salubrious, is accomplished by 
drainage (where practicable), by filling in with earth (atterrissement), and by exhaustion (by 
immense hydraulic machines, moved by steam, wind, or water). Attenissement is in some 
places successfully accomplished by utilizing the muddy water of torrents and directing it 
into the marshes where the earthly sediment is deposited, which gradually fills in the marsh 
with alluvium, making it arable. In some places in proximity to the sea, the tide water is 
employed for the same purpose, being conducted into the paludal district by means of suita- 
ble canals. 

The clearing and cultivation of marshy lands is a very dangerous operation, being, as 
Vallin says, "the first trench which one opens under fire of the enemy; the more rapidly one 
digs, the more rapidly he finds shelter from death." These clearances, then, should be 
effected as rapidly as possible, and the reclaimed land should be utilized for large plantations 
of trees, which, by the active evaporation of the leaves, dry up the soil. 

Considerable enterprise and vast sums of money have been spent in reclaiming these 
marshes, and one of the most astonishing works of modern genius is the drying up of Lake 
Facino, by Prince Torlonia, who spent more than 40,000,000 francs in this sanitary under- 
taking. 

When the marsh cannot be filled up, drained, or exhausted, it can sometimes be made 



(a) Fourcade, on the Treatment of Intermittent Fever by Hydrotherapy— These pe Paris, 1872. 



ON THE TREATMENT OF INTERMITTENT FEVER. 451 

earth, draining off the water by suitable ditches, and, finally, subjecting the 
land to thorough drying; and in many countries where marshy regions exist, 
attempts have been made by the expenditure of enormous sums of money and 
arduous labors to render those localities healthy. 

As for private hygiene, the physician and the physiologist can do much to 
establish rules as to residence and alimentation. You know that the higher 
you ascend the less you have to fear from marshy emanations; you know, too, 
that these emanations are carried to some distance by the wind, and this is the 
reason why a habitation should be chosen on a high elevation and sheltered 
from the winds that blow over the marshes. 

The dietary of the patient should be restorative, and wine should be a part 
of it; the water that is drank should be pure and free from any paludal con- 
tamination. Despite all these precautions, you will not always be able to avoid 
the malarial intoxication. Nevertheless, there remains for you one resource, 
namely, to keep the inhabitants of miasmatic countries continually under the 
influence of Peruvian bark. In fact, there is no doubt that cinchona and its 
derivatives possess a prophylactic property, and in a recent expedition to the 
gold regions of Africa, the English officers derived great benefit from the pre- 
ventive and protective use of salts of quinine. This is a very important fact, 
and I cannot too strongly recommend to you, when called to advise persons who 
are going to travel through, or sojourn in countries where this marsh miasm 
prevails, to insist upon the adoption of a prophylactic treatment by the salts of 
quinine. This finishes what I have to say about the treatment of intermittent 
fever, and I pass to the final lecture on the treatment of the eruptive fevers. 

more wholesome by converting it into a lake, by digging around it, and heaping up earth all 
about its margins, and rendering these more perpendicular, so as to diminish as far as 
possible, the extent of the surface which the waters generally leave exposed during dry 
times, (a) 



{a) Vallin, art. Marais, in Diet, encycl.— Bouchardat, Traite d'hygiene publique et priv^e, 1881.— 
Becquerel, Traits d'hygiene publique et privet, Paris, 1877, 6e eMit., p. 292.— Durand-Claye, M^moire sur le 
dessechement du lac Fucino, Paris, 1878. 



ON THE TREATMENT OE ERUPTIVE FEVERS. 

Summary. — The Eruptive Fevers — Variola — Its Prophylactic Treatment — Variolic Inocula- 
tion — History of Variolization — Vaccine — Importance of Vaccine — Its Results — Origin 
of Vaccine — Cow-pox and Horse-pox — Attenuated Virus — The Microbe of Vaccine — Ani- 
mal Vaccine and Humanized Vaccine — Vaccination — Dangers of Vaccination — Vaccinal 
Syphilis — Vaccinal Tuberculosis — Activity of Preservation by Vaccine — Conservation of 
Vaccine — Importance of Vaccination — Treatment of Small-pox — Period of Invasion — The 
Rachialgia and the Constipation — Treatment of the Eruption — Abortive Mask — Period 
of Suppuration — Disinfectant Lotions and Baths — Cardiac Complications — Ether- 
Opium Medication — Period of Desiccation — Treatment of Complications — Hygienic 
Cures — Prophylactic Treatment of Scarlet Fever — Treatment of Measles — Treatment of 
the Eruption — Treatment of the Complications. 

Gentlemen: By their symptomatic aggregate the eruptive fevers consti- 
tute a natural group in the class of fevers, and the therapeutic indications 
which pertain to them deserve to arrest our attention for a short time. Of 
these so-called zymotic fevers, small-pox possesses especial interest on account 
of the prophylactic treatment peculiar to this disease, and on this subject I 
have a good deal to say. 

In consequence of the hideous aspect which the face presents when 
covered with pustules, the repulsive odor that comes from the patient, the 
unsightly cicatrices which the malady leaves behind it, and its extreme con 
tagiousness, small-pox deserves to be regarded as one of the most terrible of 
epidemics, and it is an important duty, on the first appearance of this for- 
midable scourge, to endeavor by every means to limit its ravages. 1 

Do not persuade yourselves, gentlemen, that this word "ravages" is a figure 
of speech; it is, on the contrary, the rigorous expression of the truth. When 
in fact small-pox smites populations which have had no protection or im- 
munity from the disease, as is sometimes seen in certain races that inhabit 
the interior of Africa, or the Polynesian Islands, whole communities have 
been swept away by the lethal epidemic, and you can judge of the fatality 

1 It is unknown at what epoch the first epidemics of small-pox appeared. It is said 
that in the books of Brahmins, dating back three thousand years, descriptions of small-pox 
have been given. It has been stated that this disease also reigned endemically in China, 
and some even affirm that variola was one of the seven plagues of Egypt; others claim that 
it was contemporaneous with the birth of Mahomet in 573. What is certain is that the Arabs 
and Rhazes in particular were acquainted with small-pox, and that the latter taught the treat- 
ment of the disease by cold baths. The Arabs passed over the disease to the Spaniards, and 
the latter introduced it into America. 

In France, in the sixteenth century, Gregory, of Tours, designated small-pox under 
the name of morbus varius, from whence came the name of variola; Marius, bishop of 
Avranches, gave it the name of varus, whence it derived the name veroh (pox) and to which 
a diminutive has been added to distinguish it from the disease which Voltaire called its 
elder sister (a) 



(a) Barthelemy, Researches on Small-pox. Thfeses de Paris, 1880. 

452 



ON THE TREATMENT OF ERUPTIVE FEVERS. 453 



of these epidemics, in recalling what happened only five years ago (in 1880), 
at the time of the arrival in Paris of a tribe of Esquimaux, which con- 
tracted small-pox during its peregrinations in Europe. All were attacked, 
and all succumbed. The observation of facts furnished a first means of 
preservation; it was remarked that persons who had once had the disease 
were ever after protected from its invasion, and either as the result of acci- 
dent, or by a process of experimentation, inoculation for the prevention of 
small-pox came into vogue. 

This inoculation or variolation has been, for many centuries, practiced 
by the Chinese, who make use of pock-scabs, which they introduce into 
the nasal fossa. 1 Then it was put in use in Circassia to protect young girls 

1 Variolization, or inoculation for small-pox as a prophylactic means, dates from the 
most remote antiquity. Practised in Georgia, in Circassia, in China, in India and in 
Persia, it was introduced later, in 1673, into Turkey by Timoni and Pitarino; thence it 
was imported into England, into most of the states of Europe, and finally into France. 
The operation was performed at all ages and in all seasons; pregnancy, menstruation, 
epidemic diseases and acute phlegmasias alone contra-indicating it. Variolization was 
practised by causing the dried scabs in fine powder to be aspirated by the nose (as in 
China), or the patient was inoculated with it by applying the matter to the skin denuded 
by a blister or otherwise broken by a seton, an incision or a prick. In England and in 
France the pock matter was pricked into the skin, the inner part of the arm being chosen 
for this purpose. 

The variolization having been performed, certain peculiar phenomena follow. In 
spontaneous variola, there is only one eruption, which spreads indiscriminately over the 
whole body. In inoculated variola there are two eruptions. For seven or eight days the 
patient is without fever, and there are only local symptoms; a gradual development from 
the point of inoculation of a pustule which about the eleventh or twelfth day dries up and 
leaves a cicatrix. About the eighth day, to the local disease succeeds a general constitu- 
tional disturbance with a heavy feeling in the head, malaise, chills, fever, nausea, vomiting 
and three days after, the appearance of a secondary eruption which begins on the face to 
extend to the neck, thorax and limbs. These pimples, which are in greater or less 
number according to the individual, enter into suppuration at the end of three days and 
follow to the end the habitual march of the pustules of small-pox of the most mild form, 
without leaving any cicatrices. 

By the side of the advantages which variolization procures: mildness of the febrile 
phenomena, diminution of the number of pustules, abbreviation of the duration of the 
disease, and especially attenuation of its gravity, must be reckoned special inconveniences 
to the subject and to his family. The disease engendered by the inoculation may some- 
times be of a very grave character, and always by these inoculations made on several 
persons, foci of the disease are created which may cause it to spread. 

It was in the heighth of the popularity of inoculation that Jen.ier came upon the stage, 
and revealed to the world his marvelous discovery of vaccine, (a) 



(a) Timoni, Historia varloUrum quse per incisionem excitantur, Constance, 1715.— Maitland, Account 
of inoculating the small-pox, London, 1722.— De La Condamine, Memoire sur l'inoculation de la petite veYole, 
Paris, 1754. Histoire de l'inoculation de la petite verole, Paris. 1776. Montucla, Recueil de pieces concernant 
l'inoculation de la petite verole, Paris, 1757. — Tissot, l'inoculation justifiee, Lausanne, 1754. — Gatti, Eclair- 
cissements sur l'inoculation de la petite verole, 1764. Reflexions sur les prejuges qui s'opposent aux progres et 
aux perfectionnements de l'inoculation, Bruxelles, 1766. Nouvelles reflexions sur la pratique de l'inoculation, 
1766. — Wrisberg, De inoculatione variolarum, Gottingue, 1765.— Petit (Ant.), Premier rapport en faveur de 
l'inoculation, 1766. — Gaudoyer de Poigny, Traite" pratique de l'inoculation, Mancy, 1768. — Dunsdale, the 
present method of inoculation and small-pox, London, 1766, 1767, 1772. Tracts on inoculation, 1782. — Noel, 
Traite pratique de l'inoculation, Reims, 1789. — Satinade, Traite pratique de l'inoculation, Paris, an VII.— 
Desotens et Valentin, Traite historique et pratique de l'inoculation, Paris, 1800. 



454 ON THE TREATMENT OF ERUPTIVE FEVERS. 

who were to be sold in the markets of .Constantinople, and it is from this 
source that the wife of the English Ambassador, Lady Mary Wortley Montague, 
in 1721, obtained her knowledge of inoculation, which she communicated to the 
people of her country; whereupon this practice speedily spread over all 
Europe. But, notwithstanding all the precautions that were taken, this 
variolation was not without danger, for inoculation from a mild case of the 
disease may engender small-pox in its most serious form, and although a 
real progress was made by inoculation, there was, nevertheless, a mortality 
of at least one in three hundred. Jenner, who was, as you know, a physician- 
inoculator in England, by his immortal discovery, substituted vaccination for 
inoculation, and from henceforth civilized man was in possession of a perfect 
prophylactic treatment for small-pox. 1 

1 Known and practised, as it is said, for ages in India, Persia, and even by the aborigines 
of South America, vaccination had not yet been introduced into Europe, and at the moment 
when Jenner made his first trials with animal vaccine in England, variolization was greatly 
in vogue. Certain physicians had remarked that some persons remained refractory to the 
inoculation of small-pox virus, and that these were generally persons who had before pre- 
sented a pustular eruption on the hands contracted from milking cows affected with cow 
pox, but these observations passed unperceived and unappreciated. It was reserved to 
Jenner to derive profit from these observations, and after long researches, to bring into 
general usage the practice of vaccination. 

Edward Jenner, born at Berkley, Gloucester county, England, in May, 1749, had for 
twenty years for his first teacher Ludlow, a surgeon of Sodsberg, and it is from him they 
say, that he learned accidentally that the cow disease preserves from small-pox. 

His second master was John Hunter with whom he was always on the most intimate 
terms. Charged with the performance of variolic inoculations in the county in which he 
practised, Jenner noted that certain persons were refractory to inoculation, and thus 
escaped the contagion of small-pox. He observed, moreover, that these same individuals 
employed on farms had previously been affected with pustular eruptions on the hands, 
which they seemed to have contracted by milking cows, which had like eruptions on 
their teats. 

Struck by these facts, he undertook various experiments and attempted to substi- 
tute for the variolizations properly so-called, inoculation with the virus contained in the 
pustules developed primarily in the animal or secondarily on the human subject. 

He considered, moreover, cow pox and small-pox as having for first origin one sole 
and same disease, an affection of the horse called grease, and which in France is called 
eaux aux jambes. According to him, cow pox comes from horse pox, and is communicated 
by the stable-boys charged with the care of horses and the milking the cows. Jenner 
made his first experiment on his own son in 1789; he inoculated him with swine pox, 
then a little while after he variolized him; the disease did not take. 

In 1796 he took from the hands of a farm girl, Sarah Holmes, the virus contained 
in some pustules, acquired from milking cows, and he inoculated a child by the name of 
Phipps; the eruption appeared at the points of inoculation, and four months after he 
variolized the child, the infection did not take, the child seeming to be fully protected. The 
vaccine discovery was made, but it was not till two years later, in 1798, that Jenner pub- 
lished the results of his experiments in a little book of sixty pages. 

Physicians rallied around Jenner, and among them Pearson was the first to repeat the 
experiments, and with the same results. But like Simmons, Coleman, and other experi- 
menters, they did not believe with Jenner that cow pox was derived from the grease of horses. 
Woodville, physician to the hospital for inoculations in London, having found a case of 
spontaneous cow-pox, made experiments with it; he noticed that the eruptions were not all 



ON THE TREATMENT OF ERUPTIVE FEVERS. 455 

I shall not here discuss the value of vaccination. I am aware that there 
exists a small and uninfluential group of physicians who, under the name of 
anti-vaccinators, pretend that not only is the discovery of Jenner inefficacious, 
but that it is even dangerous; but their specious arguments have not lessened 
the preservative value of vaccine, 2 a value to-day indisputable, and which all 
the countries of Europe and of the world make haste to recognize, by favoring 
the promotion of vaccination, and by making it a legal obligation. France has 
not yet enforced this obligation by legislative enactment, although it has done 
so in a round-about way, by making attendance at schools and military service 
obligatory, and in requiring a certificate of vaccination and of revaccination as 
a condition of admission to the public schools and the army. 

I shall not examine here all the questions which the origin of vaccine has 



alike, and that there was in some cases a real variolic rash. Woodville concluded from this 
that pustular eruptions were a part of the vaccine disease, and that cow-pox was but a variety 
of small-pox. But later he abandoned this view; his last experiments were made with more 
care and he obtained the results announced by Jenner. His first experiments were defective; 
in fact he confessed that sometimes he inoculated with small-pox matter at the same time as 
the vaccine, or several days later. He also made these operations in a hospital where small- 
pox was prevailing. 

The works of Jenner and his partisans rapidly spread the knowledge of vaccine to 
Hanover, Germany, Austria, France, Italy and even America. It was everywhere practised, 
despite the obstacles which were put in its way by numerous adversaries (Mosely, Vaunie, 
Herz, etc.) 

The disparagers of vaccine have accused Jenner of not having faith in his own dis- 
covery, because in 1799, after having vaccinated without success his son Robert, who was 
living in a district infected with small pox, and not being able to procure genuine cow-pox 
matter, he variolized the child. 

As in the case of all discoveries, the claim of Jenner to the discovery of vaccine was 
contested, and in France even, it was said that Jenner had been anticipated by a protestant 
minister of Montpelier. Whether this be true or not, it is none the less indisputable that if 
the idea did not first originate with Jenner, to him alone belongs the glory and the merit of 
having propagated the practice of vaccination. 

Besides questions pertaining to medicine Jenner occupied himself much with natural 
history and published various works on this subject. He died loaded with honors at the age 
of 64 years; he had a first attack of apoplexy in 1820; he recovered, but in January, 1823, a 
second attack carried him off. (a) 

2 To judge of the relative mortality of small-pox before and after the discovery of 
vaccine, we need only consult the tables of Lotz, of Bale. The latter affirms that in the 
last century a twelfth of the population of Europe succumbed to variola. 

The following table will be of interest at the present day amid the scepticism provoked 
by the wide spread literature of anti-vaccinationists: 



{a) Jenner (Edw.), An inquiry into the cause and effects of the variolic vacc, London, 1798, trad, 
franc, par de la Roque, Lyon, 1800. Further observations on the variolic vaccine or cow-pox, 1799. Appen- 
dix to the treatise on cow-pox, 1800. A comparative statement of tracts and observations relative to the cow- 
pox, 1800. On the origin of the vaccine inoculation, 1801. On the varieties and modifications of the 
vaccine pustule occasioned by an imperfect state of the skin, 1819. — Woodville, reports of a series of inocula- 
tion of variolic vaccine or cow-pox, Londres, 1799. — Pearsey, Recherches historiques sur la vaccine, Londres, 
1798. — Vaunie, Reflexions sur la nouvelle mdthode d'inoculation.— Herz (Marcus), in Journ. de Hufel., vol. 
XII, 1801.— Baron, the life of Edw. Jenner, with illustrations of his doctrines, London, 1838. 



456 



ON THE TREATMENT OF ERUPTIVE FEVERS. 



raised, 3 viz., whether it comes exclusively from the cow or in the first instance 
from the horse. Whether cow-pox and horse-pox are anything but real small- 
pox developed in animals? Whether there is identity between human variola 
and animal variola? These are problems of experimental physiology which are 
far from being solved, despite numerous laborious investigations, in particular 
those of the veterinary school of Lyons and its chief Chauveau. Yes, it seems 
demonstrated that horse-pox and cow-pox are the small-pox of the horse and 
cow, but when you come to inoculate these animals with the human pock you 



Names of Countries. 



Lower Austria 

Upper Austria 

Styria 

Illyria 

Trieste 

Tyrol and Voralberg. 

Bohemia 

Moravia , 

Austrian Silesia 

Galicia 

Bucowina 

Berlin 

Sweden 

Copenhagen , 



Period Before and After the Intro- 
duction of Vaccine, to which Be- 
long the Figures Pertaining to the 
Mortality from Small-pox. 



1777 
1777 
1777 
1777 
1777 
1777 

1777 

1777 
1777 
1777 

1777 
1781 

1774 
i75i 



1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1806 and 1807 
1805 and 1810 
1801 and 1801 
1800 and 1801 



1850 
1850 
1850 
1850 
1850 
1850 
1850 
1850 
1850 
1850 
1850 
1850 
1850 
1850 



Annual Average of Mor- 
tality in Each Million 
of Inhabitants. 



Before the 
Introduction 
of Vaccine. 



2484 
1421 

1052 

518 

14036 

911 

2174 

5402 

5812 

1194 

3527 

3422 

2050 

3128 



After the 
Introduction 
of Vaccine. 



340 
5or 
446 
244 
182 
170 
251 
255 
198 
676 
516 
176 
158 
286 (a) 



3 Jenner admitted as the origin of vaccine a disease of horses' heels, which being trans- 
mitted to the cow by the dirty hands of milk men employed in treating the sick horses, is 
transformed into cow-pox. He at first called this disease the grease, and later he gave it the 
name of sore heels; a name which is the equivalent of eaux aux jambes; which our veterinary 
surgeons apply to the same disease. It is to-day known that this horse disease is not the 
true origin of cow-pox and does not preserve the animal from small-pox, but that there 
exists another disease which Bouley calls natural horse pox. 

This natural horse-pox was observed in France, in i860, at Rieumes, near Toulouse, 
by Laforgne, and in 1863, by Bouley, at the veterinary school of Alfort. 

This horse pox is an eruptive vesiculo-pustular disease which is seated especially on 



(a) Lotz, Variola and Vaccine. 
Bale. 1881. 



Report made in the name of the Sanitary Federal Commission. 



ON THE TREATMENT OF ERUPTIVE FEVERS. 457 

obtain a product which gives you for the human subject not kine-pox but small 
pox. The identity of vaccine virus and variola virus is only a hypothesis, but 
which will, it is hoped, shortly become a scientific reality, thanks to the brilliant 
discovery of attenuated virus by our illustrious colleague Pasteur. 

I cannot here resist the desire to say a few words concerning this doctrine, 
which, originating only a few years ago, occupies so great a place in the pro- 
phylactic treatment of diseases, and which has thrown so much light on the 
history of virulent and infectious maladies. 

Carrying out the fruitful line of inquiry suggested by vaccination, Pasteur 
has shown that it is possible by special cultures of microbes, 4 the supposed 

the skin and on the buccal and nasal mucous membranes, and exceptionally on the coi^ 
junctiva. On the skin, the eruption has for seat of predilection the lower portion of the 
limbs and the head. This eruption is accompanied by a slight febrile movement which 
comes on three or four days before the appearance of the vesico-pustules. The confluence of 
the eruption on the legs produces congestion, swelling and ulceration, and it is easy to 
understand the confusion which has been made between the eaux aux jambes (leg waters) 
and horse-pox. 

Chauveau, Viennois and Meynert have studied artificial horse-pox, that is to say, that 
which results from the inoculation of humanized vaccine on the horse, and have shown the 
differences which exist when inoculations or injections are made in the veins or in the cel- 
lular tissue, or when the product is introduced by the respiratory passages. 

In the cow there exists also a vesiculo-pustular eruptive fever which has been described 
under the name of cow-pox, and which may be produced as in the horse by the inoculation of 
vaccine matter. 

Attempts have been made to ascertain if cow-pox, horse-pox and small-pox are the 
same disease, and this opinion of the unity of the three diseases has been maintained by 
Jenner, by Thiele, and by Ceely; and it has been the subject of numerous discussions before 
the Academy of Medicine, especially in 1863 and 1864. Depaul has been the most ardent 
defender of this unity, which has been combatted by Bousquet, and this view may be 
summed up in these words: "There is no special vaccine virus. The latter is nothing but 
small-pox virus in its action on the cow and the horse." 

Unfortunately experiments which have been made down to the present time have not 
solved this question, and the researches of the Commission of Lyons show that when you 
inoculate with human small-pox the horse and the cow, you give them a different eruption 
from horse-pox and cow-pox; and that if you take the product of this eruption and inoculate 
man with it you do not produce the vaccine disease but genuine small-pox. (a) 

4 Thus far inoculation by attenuated virus has been practiced in three affections: 
chicken cholera, anthrax and swine plague. 

The virus of chicken cholera is one of the most active. It owes this activity to certain 
bacilli which develop in the blood and in the entire organism of the fowl. By the culture of 
this bacillus, one may succeed in attenuating its virulence and creating a variety of microbe 
which always reproducing its kind is capable of preserving chickens without determining in 
them cholera. As for anthrax (charbon), the first attempt at attenuation was made by 
Toussaint, of Toulouse, who raised to the temperature of 50 C. defibrinated blood of an 



(a) Jenner, An inquiry into the causes and effects of the variolic vaccine, a disease discovered in some 
of the western counties of England, particularly Gloucestershire, and known by the name of cow-pox, 
London, 1798. — Lav, Account of some experiments on the origin of cow-pox, 1802 et Bibl. brit., t, XXI, p. 
377. — Bouley, Lecons de pathologie comparee, Paris, p. 175, 1882. — Bousput, De l'origine de la vaccine chez le 
cheval, rapport sur le memoire de M. Laforgue (de Toulouse) (Acad, de m^d., 27 mai 1862). — Chauveau, 
Viennois et Meynet, Vaccine et variole. nouvelle dtude sur l'identite' de ces deux affections (Acad, de 
m^d., 30 mai 1865, et Gaz. hebd. de med. et dechir., 1865, p. 354).— Warlomont, Traite de la vaccine, 1883, p. 55. 



458 ON THE TREATMENT OF ERUPTIVE FEVERS. 

agents of contagion in virulent diseases, to change the character of the bacilli, 
or, to use the happy expression of Bouley, to domesticate them, and thereby 
create new varieties, which, while maintaining a protective power on the animal 
in which they have been inoculated, develop only a mild form of the original 
disease. This is what he has accomplished for chicken cholera, for swine 
plague, and especially for anthrax, or splenic fever, and to-day it is by tens of 
thousands that we count the flocks and herds that he has saved from this deadly 
anthrax by his experimental vaccination. It ought to be the same for small- 
pox and vaccine, but we have not yet found methods of culture for developing 
the variola virus, and it is necessary that small-pox should undergo attenuation 
in the organisms of certain animals, such as the horse and cow, before the re- 
sulting virus can be truly protective. 

Does the vaccine virus, you may ask, contain a microbe? Undoubtedly; 
and Klebs considers it as absolutely identical with that of small-pox. Chauveau, 
moreover, showed us in 1868 that vaccinal lymph deprived of its solid corpus- 
cles, becomes inert. 5 



animal affected with charbon, and it was with this blood that he prepared his vaccinal 
liquid. Pasteur, Roux and Chamberland succeeded on cultivating the bacteria in obtaining 
a variety of these micro-organisms which reproduced themselves only by scission and with- 
out spores. This kind of bacterium was obtained by cultivating the anthrax bacillus in a 
culture liquid at the temperature of 42 to 43 C. These bacteria, deprived thus of spores, 
lost their virulence and served for attenuated virus. 

One may, with these varieties of attenuated bacteria of chicken cholera and of charbon 
reproduce the virulent species, and for this purpose it suffices to inoculate these bacteria in 
certain species of animals of small size, the guinea pig for charbon, the sparrow for chicken 
cholera; then to take the microbe which develops in these organisms and subject it to another 
culture, and thus by successive cultures we succeed ill reconstituting the original virulence 
of these bacteria. To-day these preventive inoculations for charbon are an accomplished 
fact of immense practical importance, and it is by the thousands that such inoculations are 
practiced among sheep in all the countries of Europe. 

Detmers, of Chicago, afterwards Thuillier, of France, have discovered a microbe in the 
blood of hogs infested with swine plague. Pasteur and Thuillier have attenuated the virus 
and modified the microbe in causing it successively to pass through the pigeon and the hare, 
and this attenuated microbe inoculated in hogs, preserves them at least a year from swine 
plague, (a) g 

5 Gluge, in 1838, was the first to describe in vaccinal lymph certain crystals which he 
believed to be the essential principle of this lymph. These crystals were nothing but bril- 
liant corpuscles, which have been since described under the name of corpuscles of Gluge. 
Chauveau, in 1868, pointed out this capital fact, that when we deprive vaccine matter of the 
corpuscular elements which it contains, the vaccinal lymph becomes inactive. To obtain this 
complete separation, Chauveau employed the process of diffusion, and to a stratum of 
virulent liquid he added, carefully and slowly, a stratum of water; intermingling took place, 
and all the soluble parts of the serum were diffused through the water; the upper part of this 
mixture, when animals were inoculated with it, did not reproduce the vaccine. According to 
Hiller, the contagious principle of vaccine resides in certain pale opaque granules, some 



(a) Bouley, Lecons de pathologie comparee, Le progres en m^dic'ne par l'experimentations. — Duclaux, 
Ferments et maladies, Paris, 1882.— Dujardin-Beaumetz, art. BacteVie, Diet de theY.— Chamberland, Revue 
scientifique, mai 1882. — Pasteur et Thuillier, Du virus attdnue au rouget des pores (Acad, de med., stance du 
27 novembre 1883). 



ON THE TREATMENT OF ERUPTIVE FEVERS. 459 

You all know the methods of vaccination, and I need not here give you 
any rules for this operation, nor any description of the vaccinal eruption, 6 only 
reminding you that it seems to-day demonstrated that the number of vaccina- 
tions, and the intensity of the vaccinal eruption, have a certain part in the pro- 
tection conferred, and the statistics of Oppert and of Russell seem to me in this 

soluble in solution of potassa, others insoluble. Klebs believes that he has found the microbe 
of vaccine; he claims that it is identical with that of small-pox; it has for dimensions yof on °* a 
millimetre; it presents itself often in groups of four, whence the name of micrococcus 
quadrige minus, (a) 

6 The regular vaccinal eruption is developed in the following manner (Bousquet): The 
first and the second day one sees nothing unless it be some little hyperaemiain the punctures, 
but to inexperienced eyes the vaccinated subject is as if nothing had happened; it is the 
period of incubation common to all contagious diseases and especially to eruptive fevers. 
From the third to the fourth day, a little sooner in summer, a little later in winter, there is 
seen on each point of puncture a reel point, more sensible to the touch than to the sight; in 
fact the finger distinguishes very clearly a little engorgement, just commencing, but soon 
to increase. 

The fifth day, counting from that of inoculation, or the second day of the eruption, this 
pimple has become larger, but still without any particular characteristic. 

On the sixth day it is no longer possible to be mistaken. Instead of developing to- 
wards a point as it had commenced to do, the pimple enlarges, flattens, becomes slightly 
cupped in the centre and takes on a silvery white, shading a little into a blue color. At the 
same time the base is surrounded with a little circle still very circumscribed but which spreads 
further each day. 

The seventh and eighth day the same symptoms a little more marked. The pustule 
then fully formed, presents itself with its distinctive characters; is one or two lines in 
breadth, of a slightly azure white color, surrounded by an aureola of considerable extent, 
depressed in its centre, and terminated by hard swollen borders more elevated than the 
rest of the surface. 

The ninth and tenth day this congeries of symptoms acquires still more intensity, but 
the most remarkable change takes place in the aureola, whose color, more bright and more 
red, disappears with greater difficulty on pressure of the finger and extends nine or ten 
lines in every direction. The subjacent parts are engorged, and this engorgement is pro- 
portioned to the extent and intensity of the areola. 

From the eleventh day the papule begins to fade; the silvery blue changes and becomes 
brown; the areola contracts, grows pale, and yellowish; finally from the twelfth to the 
thirteenth day the pimple dries up and is transformed into a hard black crust, which falls on 
the twentieth or twenty-fifth day, and leaves in its place an indelible cicatrix, so character- 
istic that an experienced person can always tell what was its source. 

The vaccinal cicatrix is round, deep pitted, traversed with rays and studded with a 
multitude of little black points which correspond without doubt to the cells which the pimples 
contained in their interior. It is superfluous to add that the older the cicatrix the more it is 
confounded with the integument, but it is never entirely effaced. 

Such is the pustule obtained by human vaccine; with animal vaccine there are certain 
slight differences. The pustules are ordinarily more voluminous, more flat, more white; the 
march of the eruption is slower and its local action more violent, and sometimes accompanied 
with engorgement of the glands of the axilla. 

Kine pox sometimes presents irregularities. The period of incubation which lasts 



{a) Gluge, Anatom. Microscop., Winden, 1838. Chauveau, Nature des Virus, etc., Acad, des Sc, Feb'yi 
1868. Klebs, Arch, fur Experim. Path., t. x., p. 2 and 3. Hiller, Untersuchungen iiber das Contagium der 
Kuhpocken, Centrabl., No. 20 et 21, 1876. 



460 ON THE TREATMENT OF ERUPTIVE FEVERS. 

respect to be very conclusive. 7 But one point on which I ought to insist is the 
necessity of re-vaccination; in fact, vaccine seems to lose its protective proper- 
ties in about ten years; therefore, all the governments which have made vac- 
cination compulsory have been careful to enjoin revaccination. 

Of all the dangers which have been attributed to vaccine, there is but one 
which deserves your serious consideration: it is the possibility of inoculating 
syphilis when the matter is taken from a syphilitic subject. 8 To-day it is per- 
fectly demonstrated, and by observations, unhappily too numerous, which 
amount in our country to more than 120 cases, that vaccinal syphilis exists, and 
that too much care cannot be taken in the choice of the subject from whom 
vaccine matter is obtained. This consideration has had a good deal to do 
with the success which has attended animal vaccine, a kind of vaccination 
which Lanoix and Chambon imported from Italy in 1856 to our country, 
and you may see in this hospital the success which has been obtained by 
this bovine vaccination, to-day adopted by all the countries in Europe as 

ordinarily from three to four days may be prolonged even to the fifteenth or twentieth day. 
In the eruption one sometimes sees the pimples develop not simultaneously but progressively, 
the one after the other. Sometimes, also, there develop more pustules than there were 
pricks, and they are met with not only on the parts inoculated, but also over the whole body. 
These cases are especially seen in children affected with impetigo. This diffused eruption is 
unfortunate from the reaction which it occasions, and especially from the indelible cicatrices 
which it leaves behind. So in the case of children affected with rashes it is well to be 
prudent; if there is no epidemic of small-pox prevailing, one may put off vaccination; if 
there is fear of contagion, one need not make but one or two punctures. 

In certain cases where inoculation is made very deep, no pimple is produced, and 
yet the individual may be preserved, as the late observation of Rene Blache has shown. (a) 

7 According to Oppert, the greater the number of raised pustules, the more complete the 
protection. He gives a table of observations which go to confirm this view. 

8 Vaccinal syphilis is to-day admitted without dispute by all observers, and Viennois 
in i860 had collected more than sixty-seven observations. In France we may reckon at 
one hundred and twenty the number of cases of vaccinal syphilis recorded. In Italy the 
number amounts to three hundred. In England there have been but thirty-six instances. 
One may, moreover, on this subject consult the interesting statistics of Lotz, of Bale. As 
for France, the number of persons infected, which as we have just mentioned amounts to 
one hundred and twenty, since attention was first called to vaccinal syphilis, might be aug- 
mented by more than twenty cases observed in the garrison at Algiers. Many hypotheses 
have been put forth to explain the introduction of syphilis by vaccine. 

1. The hypothesis of direct inoculation by a lancet which has been in contact with 
chancrous pus, or by the contact of cloths soiled by pus of the same nature, the vaccinal 
abrasion taking the infection, or by possible inoculation with syphilitic blood. 

This last hypothesis has been experimentally verified in Italy by Pellizari who in 1862 
inoculated his pupil, Dr. Bargioni, with syphilis by employing blood taken from the 
cephalic vein of a woman of twenty-five years of age affected with constitutional syphilis, {b) 



(a) Brusquet, Treatise on vaccine.— -R. Blache, Efficacious vaccine without cutaneous manifestations, 
(Rev. mens, des malad. de l'enfance, Dec. 1883). 

(3) Viennois, De la transmission de la syphilis par la vaccination (Arch. gen. de med., 1890, t. 1, p. 640, 
t. II, p. 32 et 297).— Depaul, la Syphilis vaccinale (Acad, de med., decembre 1864 et fevrier 1865).— Lotz (de 
Bale), Variole et vaccine, Bale, 1880 p. 107. — Millard, Sur un cas de syphilis vaccinale (Union med, decembre 
1865, No. 147, p. 466). 



ON THE TREATMENT OF ERUPTIVE FEVERS. 461 

well as in America. For my part, I consider animal vaccine just as good 
as human vaccine, with this advantage, that there is certainty of exemption 
from the danger of syphilis. 

But now that the experiments of Villemin have been strongly confirmed 
by the discovery of the bacillus tuberculosis, one may ask if in this way tuber- 
culosis, so frequent in kine, may not be transmissible by vaccine. 1 So far we 
have had no proof of this fact, but it deserves to be discussed, and Warlo- 
mont, in his interesting work on vaccine, has devoted to the refutation of the 
possibility of inoculation of tuberculosis by animal vaccine, an interesting chap- 
ter, to which I refer you. 

Whether it comes from the infant or from the animal, vaccine matter may 
be preserved a considerable time. At our Academy of Medicine, where the 
humanized lymph alone is used, the vaccine is kept only in capillary and glass 
tubes. In countries where they make exclusive use of animal vaccine, which 
is more difficult of preservation, they employ the scabs, or dried pustules re- 
duced to powder or paste, and my pupil, Dr. Crando, of Nice, has shown the 
activity and the easy preservation of these vaccinal preparations. 2 

1 Toussaint has made experiments respecting the possibility of inoculation of tuber- 
culosis by vaccination. 

With a vaccine pustule from a child in excellent health and the issue of robust parents, 
he inoculated a tuberculous cow; with the serum from pustules thus produced in the cow, he 
inoculated four hares and a hog; two of the hares, killed two months afterwards, showed all 
the lesions of tuberculosis. 

As for the hog, it also became tuberculous. Vulpian in commenting on this communi- 
cation, observes that it is with great reservation that one should accept Toussaint's results. 
Moreover, he remarks that it is not till after having produced these experiments a great 
number of times with positive results that one should admit the possibility of this in- 
oculation, (a) 

[Fearing the possibility of syphilitic contamination by using humanized lymph, physi- 
cians in America largely rely on animal or bovine matter, of which there are many excellent 
sources of supply in this country. The danger of communication of tuberculosis by animal 
vaccine is so slight as to be practically excluded. The bovine lymph is more severe in its 
effects than the humanized, producing often considerable constitutional reaction and a more 
or less diffused eruption. I am certain that I have seen septicemic symptoms developed 
from impure quality of the lymph, for producers, eager to make the most of the occasion, are 
not always particular to charge their points only with the pure watery lymph which oozes 
from the papule of the heifer on the sixth or seventh day, but they by artificial means teaze 
out more vaccine matter and this is often contaminated with blood. It cannot be too 
much impressed on vaccinators, that whether humanized or animal vaccine be used, only 
he clear water that at the end of a week oozes from the papule is suitable, and that the 
admixture of pus or blood (and on this account the dried crusts are reprehensible) engenders 
danger from septicaemia. — Trans.] 

2 Animal or human vaccine is preserved in different ways: 

Tubes. — Here the vaccine is in a liquid form and preserved in capillary tubes. You 
break the tubes when you wish to use the vaccine. 

Glass Plates. — You can collect and keep the vaccine between two flat pieces of glass, 
and it suffices to moisten these plates with saliva to have the vaccine fit for use. 



(a) Toussaint, Tuberculous infection by the liquids of secretion and serosity of vaccine pustules. 
Comptes rendus de la stance du 8 Aug. 1881.) 



462 ON THE TREATMENT OF ERUPTIVE FEVERS. 

Vaccine constitutes, with hygienic means of isolation, the only prophylactic 
treatment of variola; all others are illusory, and even dangerous. 3 The 
hygienic measures comprise an aggregate of means for the isolation of the 
patient — means especially necessary in our hospitals — and you see to-day the 
good effects of this isolation, thanks to the measures, incomplete it is true, 
which have been adopted by the Board of Public Charities, and the Prefecture 
of Police, which have put at our disposal certain isolated barracks and special 
vehicles for the transportation of small-pox patients. 

We know at the present day almost with certainty the mode in which the 
contagion of small-pox is received into the system, namely by the respiratory 
passages, 4 in most cases, if we can rely on the experiments of Zulzer on 
animals. Brouardel had in fact previously shown us by examination of the air 
of small-pox wards, that this atmosphere was charged with numerous particles 
coming from desiccated variola pustules, and it is by the penetration of these 
particles into the respiratory passages that small-pox virus enters the blood. 
From these experiments, too, we may conclude that at the period of desiccation 

Under these two forms the Academy of Medicine exports human vaccine, the tubes 
being much preferable to the glass plates. 

Ivory points. — Instead of glass plates you may make use of ivory points about as thick 
as playing cards. These ivory points covered with vaccine, are passed back and forth over 
scarifications made in the skin, being previously moistened with a drop of warm water. 

Animal vaccine is much more difficult of preservation; in Italy they make use of 
powdered crusts, kept in stoppered tubes, and vaccine paste. 

[In this country animal vaccine comes to us from the dealers in this commodity chiefly 
in the form of ivory points, capillary tubes and scabs. The ivory points and the tubes are 
alone to be relied upon. The use of scabs is a filthy method, and does not seem to be wholly 
unattended with the risk of septicaemia. Personally, I like very much the lymph that is one 
remove from the heifer. A healthy child, known to be free from tuberculosis, syphilis, etc., 
of good parentage, is selected and vaccinated with matter from the cow. If the vaccine 
"takes," on the day that the watery lymph exudes from the papule, quills or ivory points are 
charged with this virus. Enough in that way to vaccinate thirty or forty persons can be 
obtained. This humanized matter is much milder than the animal vaccine, and seems to 
afford equal protection. — Trans.] 

3 Theodore Ruth, of Enten, has instituted the use of vinegar as a prophylactic means 
in the treatment of small-pox; his method consists in the administration for fifteen days of 
a couple of tablespooufuls several times a day of vinegar, pure or with water. He also 
employs the aromatic vinegar which has besides acetic acid, camphor, garlic, lavender and 
nutmeg. 

Roth has by this treatment in a hundred and six cases saved his small-pox patients. 
According to him, the origin of the name of aromatic vinegar (quatre voleurs) comes from 
the circumstance that at Madrid certain thieves (voleurs) were preserved from the epidemic 
by employing this vinegar, (a) 

4 Zulzer has studied in the monkey the modes of transmission of small-pox. Accord- 
ing to his experiments, it results that the blood of the victims of small-pox is infectious, that 
the infection is not communicated through the digestive apparatus nor through the unbroken 
skin, but almost exclusively through the air of respiration, (b) 

c 

(a) Deutsch. Klin. No. 40, Oct. 5, 1872. 

{b) Zulzer, On the etiology of variola. (Centrlbl., 1874, No. 6, 1884.) 



ON THE TREATMENT OF ERUPTIVE FEVERS. 463 

of the eruption we should redouble our efforts to prevent the dissemination of 
contagion. Unhappily, this is the period of the disease when the medical 
attendant finds himself most impotent, and till persons convalescent from 
small-pox shall be restrained by stringent legal enactments, we shall find it 
hard to prevent them from going abroad and carrying with them wherever they 
go, the contagious elements of the disease. 

As for the treatment proper of small-pox I shall have little to say; during 
the invasion we can in some cases favor determination of blood towards the 
skin by means of sudorifics, and especially the spirits of mindererus. 1 You 
will often have to combat the pain in the back, and the obstinate constipation, 
symptoms of the first stage. You can generally remedy the first by means of 
certain liniments (such as chloroform and spirits of turpentine of each one part, 
and liquid opodeldoc eight parts); the constipation can generally be overcome 
by mild purgatives. Next comes the eruption; if it is discrete, if moreover the 
subject has been vaccinated, no active interference will be required; not so if 
the eruption be confluent, and all your efforts will be required, especially if 
your patient be a young female, to prevent the eruption from following its 
course, and causing disfiguring cicatrices. For this end various means have 
been proposed. 2 Mercurial preparations, and in particular Napolitan ointment 

1 Delioux, of Savignac, employs in the first stage of small-pox and to favor eruption 
acetate of ammonia under the following formula: 

i . Take of acetate of ammonia 15 parts. 

peppermint water, 
orange flower water, 

balm water, each 30 parts. 

syrup of ether, 

syrup of maiden hair, each 30 parts. 

M. Sig. A tablespoonful every hour. 

[Instead of this formula the ordinary ( 3 ij) dose of spirits of mindereras with a few 
drops of Hoffman's anodyne would answer the purpose equally as well. — Trans.] 

To sooth the pains in the back he rubs on the following liniment: 

2. Take of chloroform, 

spirits of turpentine, each 1 part. 

opodeldoc 8 parts. 

M. Fiat linimentum. 

2 Zimmermann was the first to call attention to the property of emplastrum de vigo 
cum mercurio, of arresting the evolution of the small-pox pustules, and his trials were 
repeated by Serres in 1835. Serres made use of mercurial plaster cut up in little strips with 
which he completely covered the face of the patient. 

Briquet employs mercurial ointment mixed with starch in the following proportions: 

^ Mercurial ointment 2 parts. 

Powdered starch 1 part. 

M. 

And with this ointment he makes a coating over the face two millimetres in thickness; 
this coating to be kept always unbroken. 

Valleix thinks that this mixture is too thin, and adds equal parts of the ointment and 



464 ON THE TREATMENT OF ERUPTIVE FEVERS. 

and the emplastrum de vigo have the curious property of preventing the de- 
velopment of these pustules, and this abortive power has been utilized by 
covering the face of the patient with masks made of these preparations. Aran 
and Delioux, of Savignac, have proposed to substitute for these ointments a col- 
lodion made with corrosive sublimate; 3 unfortunately, this collodion, however 
elastic it may be supposed to be, yields readily to the distension of the skin 
attending the eruption, and notwithstanding the real advantages of this method, 
I have had to abandon it and return to the primitive process of Zimmerman. 

This is my mode of procedure: I apply thickly over the face the emplas- 
trum de vigo cum mer curio, and over the whole I dust starch powder, and I 
take care, by new layers of pomade and starch, to fill in all the fissures and 

starch. In order that these dressings may have an abortive action, they must be applied 
from the very first day of the eruption. 

Revilliod, of Geneva, applies as abortive treatment of the pustules of the face, the 
following mixture: 

Take of Napolitan ointment 5 parts . 

soap . \ 2\ " 

Glycerine 1 " 

Mix. 

This mixture should be applied before the transformation of the pustules into vesicles. 
Other topical agents have been proposed. Robert Graves made use of gutta percha. 
Schwimmer, of Bonda Pesth, employs to prevent the cicatrices, the following mixture, 
with which he makes masks which are applied to the skin and members : 

Take of phenic acid 1 part. 

olive oil 8 parts. 

Prepared chalk 12 parts. 

Mix. 

This mixture is employed in the form of a soft paste spread on strips of linen. 

Zulzer proposes to treat locally the variolic pustules by a slight compression. Under 
the influence of this compression, he says, the pustules dry up with exceeding rapidity and 
the fever diminishes, (a) 

3 Delioux, of Savignac, employs a mercurial collodion with the following formula: 

GRMS. 

Take of corrosive sublimate , o . 30 

Venice turpentine 1 . 50 

collodion 30 . 00 

M. 

This collodion is applied by a camel's hair pencil all over the face (b) 



{a) Zimmermann, Traits de l'experience, t. II.— Serres; voir Gariel, Recherches sur quelques points de 
la variole (these de Paris, 1837). — Briquet, Memoire sur l'emploi des topiques mercuriels (Arch. g6n. de m6d., 
1838).— Valleix, Lecons cliniques (Un. med., 8 fevrier 1853).— Revilliod, Variole. Traitment abortif des pus_ 
tules de la face (Journ. de pharm. et de chim., avril 1873, p. 523). — Aran, Soc. m^d. des. hop., 25 septembre 
i860. — Dujardin-Beaumetz, Soc. me'd. des hop., 1872. — Robert Graves, Bull. gen. de the"r., 30 septembre 1852. — 
Schwimmer, Zur Therapie der Variola von Standpunkte der Micrococcus-Lehre (Deuts. Arch. f. Klin. Med., 
Bd. XXV, Heft 2 et 3, p. 178).— Zuelzer, Zur Pathogenese und Mecanischen therapie dar Variola (Bert. Klin. 
Woch., 1874, 22 juin, No. 25). 

(6) Dilioux of Savignac, On the abortive treatment of small-pox pustules. (Bull, de Ther., 1845, t. xcviii. 



ON THE TREATMENT OF ERUPTIVE FEVERS. 465 

broken places which may afterwards appear in this mask. You will in this way- 
succeed when, be it understood, you have applied this protective mask at the 
very commencement of the eruption, in causing the pustules on the face to 
abort, save only those around the lips and mouth, where the incessant muscular 
movements will be likely to cause the mask to break. In certain cases you may 
employ the ectrotic method of Serres and Velpeau; a method which consists 
in opening each vesicle and cauterizing it with nitrate of silver. This process, 
which cannot be applied to confluent eruptions, ought to be reserved for the 
pustules which develop on certain points, and in particular on the cornea. As 
you well know, these pustules may, in their ulterior progress, perforate the 
cornea and destroy the eye. I have myself seen several instances of total 
blindness, due to the negligence of the attending physician, who did not inter- 
fere in time. 

On the part of the mucous membranes, your attention ought especially to 
be directed to the buccal cavity, where the eruption causes profuse salivation 
and a painful swelling of the isthmus of the fauces ; gargles of Vichy water and 
chlorate of potassium often relieve these symptoms. 

The fever has abated, the general symptoms have improved, and we come 
to the period of suppuration in patients who have not been vaccinated. Then 
there is reawakening of the fever, and the grave symptoms appear, in particu- 
lar the swelling of the hands and the feet. It is to this suppurative period that 
the efforts of therapeutists have especially been directed. It constitutes the 
most critical stage of the disease, and it is at this period, more than at any other 
time, that patients succumb. 

Earnest endeavors have, above all, been made to avoid the putrid infection 
which results from incessant contact of the denuded derm with the pus which 
bathes it on all sides, and various antiseptic preparations have been used. 
Chauffard 1 thought that he had found in phenic acid an abortive and curative 
treatment for confluent variola; Guipon, on the same principle, proposed per- 
chloride of iron; 2 and Jenna, of Buenos Ayres, spirits of turpentine. 3 All 
these medications have been abandoned, and the profession has returned to 
local treatment, and in particular to baths and lotions of disinfectant sub- 

1 Chauffard has employed crystallized carbolic acid in the treatment of the secondary 
fever of suppuration of grave confluent small-pox, and he has seen, under the influence of 
this treatment, the febrile symptoms diminish as well as the suppuration. He administers 
daily 15 grains of crystallized phenic acid in a four ounce mucilaginous potion. 

Audhoui, who has employed the same medication, made use of the following potion: 

5. Acid phenic gr. xv. 

Mucilage acaciae § iv. 

Syrup of quinine f j. 

M. Sig. — A tablespoonful every two hours. 

' 2 Guipon, of Laon, employs in the treatment of small-pox the perchloride of iron (tinc- 
ture ferri chloridi), and the daily doses have varied between 12 gtt., the minimum dose, and 
40 gtt., the maximum dose. This iron preparation acts after the manner of the abortives in 
small-pox. 

There is attenuation and suppression of the secondary fever and more feeble develop- 
§30 



466 ON THE TREATMENT OF ERUPTIVE FEVERS. 

stances/ which render us great service, and which I earnestly recommend. 
These baths should be of a temperature of 95 F., and you should add to the 
water of the bath chloral solutions, solutions of thymol or antiseptic vinegar, 
and in particular that of Pennes. Their duration should be from half to three- 
quarters of an hour, and you should have care during the bath to give some 
stimulant, as rum punch. 

I have said nothing of cold baths, 5 which have been employed in the treat- 
ment of small-pox by Konig, Winternitz, and by Clement, of Lyons. These 

ment of pustules. At the same time the perchloride of iron does not diminish the mortality 
of small-pox.(tf) 

3 Jenna counsels the use of turpentine in hemorrhagic small-pox. He gives it in potion 
in the dose of 1% drachms a day.(£) 

4 Disinfectant baths and lotions are prepared in numerous ways. Delioux, of Savig- 
nac, employs baths of hypochlorites, which consist of water containing in solution between 
three and four ounces of hypochlorite of sodium for a full bath, but he prefers tar water baths 
(about three gallons of tar water to a full bath). You make the chloral bath by adding to the 
water of the bath three ounces of chloral. 

The antiseptic vinegar of Pennes is made as follows: 

B Acid salicylic 3 parts. 

Acetate of aluminum 3 parts. 

Concentrated tincture of eucalyptus glob., 10 parts. 

" " of vervain 90 parts. 

" " of lavender 10 parts. 

" " of benzoin 1 part. 

Acetic acid of 8 degrees 10 parts. 

M. For a full bath add about three ounces of the above solution. (<;) 

5 Rhazes, whose veritable name was Abou Bekr Mohammed ben Zakarya Errazy, the 
last word of which, Errazy, means native of Rey, whence comes Rhazes, was the first to em- 
ploy cold baths in small-pox. 

The friar Rovida treated small-pox and eruptive fevers by ice. He made his patients 
drink a quart or more a day of ice water. Currie also made use of cold affusions and iced 
drinks in small-pox. Bohn says that the cold bath renders the variolic eruption more dis- 
creet. Hebra also advised cold baths in small-pox. 

Konig employs cold baths in the treatment of small-pox; they are renewed every hour, 
and even oftener when the fever is intense. This refrigerant method is applied from the 
onset of the disease. The temperature of the water, till the appearance of the pustules, ought 
to be about 43°F., but as soon as the pustules appear it must be raised to 50 . Konig asserts 
that by this method he suppresses the period of suppuration, and mitigates the intensity of 
the disease. 

Winternitz has also derived great advantages from this method. Wientraub, how- 
ever, maintains that the refrigerant applications have no advantage, and that they are not 
without danger. 

Desnos and Huchard have experimented with the treatment of cold baths in small-pox. 
According to them, the cold water does not act in a refrigerant manner in coherent, con- 

(a) Guipon, Abortive properties of perchloride of iron in small-pox. 
(3) Jenna, of Buenos Ayres, Anales des circulo-medico Argentino. 
(c) Penned vinaigre antiseptique, Bull, le Ther. t. xcii., p. 426. 



ON THE TREATMENT OF ERUPTIVE FEVERS. 467 

cold baths have quite another object, that of combating the hyperpyrexia; and 
although this practice goes back to Rhazes, it does not seem to have com- 
mended itself by its results, and for my part I have no experience with it. 

To these local measures we must add the use of disinfectant powders, such 
as compounds of salicylic acid and starch or talc, as employed by Baudon, 8 and 
painting with tincture of iodine, as practiced by Boinet, Delioux, of Savignac, 
and Pioch. 7 These dressings, joined to the baths and disinfectant lotions, en- 
able you to rid the patient of the sickening odor which he exhales. 

fluent, and hemorrhagic variola; it only possesses a sedative action to the nervous system in 
the stages of invasion and eruption. 

Clement, of Lyons, has also employed the refrigerant method in variola. He gives 
cold baths of 77 and 83°F., and follows the same practice as in the application of the 
method of Brand. He does not give these baths in the period of eruption, and only applies 
them at the moment of suppurative fever, and is guided in their administration by the 
thermic curve, (a) 

6 Baudon employs the salicylate of soda internally and externally in the treatment of 
small-pox; externally he makes use of an ointment having the following formula: 

Grammes. 

Take of salicylate of soda 4 . 

Cold cream 100 . 

M. 

And a powder with the following formula: 

Grammes. 

Take of Salicylic acid 6 . 

Talc 100. 

M. 

He first anoints the parts with the first preparation, and powders them over with the 
second.(^) 

7 It was Boinet who first recommended tincture of iodine for the local treatment of the 
small-pox pustule. Delioux, of Savignac, also advises the use of iodine, and this is his man- 
ner of procedure. He does not employ tinct. of iodine until at the period of suppuration, 
and for the pustules of the trunk and members. To avoid an intense reaction, he makes his 
applications at several intervals, first on a lower limb, then on the arm, and, lastly, on the 
different regions of the trunk, and he keeps repeating these applications until he has ob- 
tained the drying up and shrivelling of the pustules. These applications hasten cicatriza- 
tion, oppose putrid absorption, and favor the obliteration of cicatrices. He gives at the same 
time full chlorinated tar baths. 

Pioch employs the following mixture: 

Glycerine : 3 parts. 

, Tinct. iodine 1 part. 

A mixture which he applies with a camel's hair pencil every four hours. (c) 



{a) Konig, Sur le traitement de la variole [Corresp. m£d. de Boeme, No. 12, 1874.]— Weintraub, De 
1'emploi de l'eau froide dans la variole [Rev. m.6d. chir. de Vienne, 30 septembre 1874]. Clement, Du traite- 
ment de la variole par les bains froids [Lyon med., feVrier, 1877, p. 89, 153 et 225]. — Hebra, Traitd des maladies 
de la peau, t. Ier, p. 267. — Desnos et Huchard, art. Variole, in Nouv. Dici.de m&l. et de chir, — Labadie- 
Lagrave, Du froid en thdrapeutique [these d'agregation, 1878, p. 143]. 

(3) Baudon, Treatment of small-pox by salicylate of soda. (Bull. gen. de ther., 1881, t. ci., p. 448.) 
(c) Delious, of Savignac, New observations upon the abortive treatment of small-pox pustules. Bull, de 
ther., t. LXXIX, p. 97. — Pioch on the treatment of small-pox by painting with iodized glycerine. 



468 ON THE TREATMENT OF ERUPTIVE FEVERS. 

But there is a danger still more formidable than that from purulent absorp- 
tion. I refer to the cardiac complications. 1 Disnos, Huchard, and Bron- 
ardel have given us a faithful picture of the variolic endopericarditis and myo- 
carditis, and have indicated the cause of those sudden deaths which in old 
people attend the stage of suppuration. It is these troubles in the myocar- 
dium which explain the feeble pulse and the anaemic delirium which are also 
noted in this period, symptoms which we need to combat by tonics and stimu- 
lants, especially opium and ether. 

Our colleague, Du Castel, has shown us the advantages which we may de- 
rive from this ether-opium treatment, and I have myself obtained good results 
from it in the care of small-pox patients in this hospital. 2 You can employ the 
ether in subcutaneous injections, being careful to insert them as deeply as pos- 
sible; as for opium, you can give from two to four grains a day in divided 
doses of the extract. Or, you may adopt the mode of administration recom- 
mended by Constantin Paul for the delirium of febrile diseases, and give 
every hour or two ten drops of laudanum. To these means you should add 
alcohol in all its forms; also coffee, caffein, the preparations of cinchona, in a 
word, all the agents of the tonic medication. 

The period of desiccation has arrived, and to hasten the falling of the 



1 The morbid determinations which affect the heart under the influence of small-pox 
infection, have been studied, especially the last few years, by Desnos and Huchard. These 
complications are wanting in discrete small-pox with few pustulations, they are more fre- 
quent in the coherent form, which Desnos includes in the group of discrete varieties, and be- 
come constant in the confluent variety. They are characterized by inflammatory lesions of 
the myocardium, endocardium, and pericardium. 

Variolous endocarditis appears especially in discrete small-pox, where it takes on 
especially the vegetating form. Myocarditis, on the contrary, is seen in the confluent co- 
herent variolas. 

Brouardel, who has also studied the vascular lesions in small-pox, has shown that there 
is produced a sanguineous effusion in the pericardium on the posterior face of the auricle; he 
has, moreover, observed lesions affecting the aorta. 

These alterations of the heart reveal themselves by a bruit de souffle, which is soft, pro- 
found, diffuse, and transitory. There is often a reduplication of the second sound of the 
heart, the pulse becomes oscillatory, polycrotous; in fine, there is delirium, due to cerebral 
anaemia. Against this condition Huchard counsels caffeine to stimulate the heart's action. (a) 

2 Du Castel employs the following treatment in small-pox. He practices morning and 
evening a subcutaneous injection of a syringeful of ether. Morning and evening from one 
to two grains of extract of opium are given. The more intense the delirium the larger the 
dose of opium. Finally teaspoonful doses are given of a potion containing in each drachm 
20 drops of tincture of perchloride of iron. 

Pecholier, who has employed this method, has obtained favorable results from it, [b) 



{a) Desnos et Huchard, Des complications cardiaques de la variole et notament de la myocardite vario- 
leuse [Un. m£d., 1874]. — Desnos, Considerations sur le diagnostic, le pronostic et le traitement des principales 
formes de la variole [Soc. m^d. des h6p., 1870]. Notes sur les complications cardiaques de la variole et leur 
traitement [Bull, de ther., t. LXXXI, 385]. — Brouardel, Etude sur la variole. Lesions vasculaires [cceur et 
aorte] [Arch, gen de me"d., decembre 1874]. 

(<5) Du Castel, Traitement de la variole par la medication ^the're'e-opiace'e [Bull. g6n de ther., 1884, t. CI, 
p. 241]. — Pecholier, Sur un cas de variole traite par la medication ethere'e-opiace'e [Bull, de ther., 1883]. 



ON THE TREATMENT OF ERUPTIVE FEVERS. 469 

scabs, you should use soap baths and inunctions with vaseline, that pomade of 
mineral origin which renders us such service everyday. 

It is at this period that vast purulent collections form, and your attention 
should be called to this fact, for these abscesses ought to be opened early. 
There will also be an indication to endeavor by a substantial dietary regime to 
repair the profound alterations which the disease has left behind it. 

Such are the principal therapeutic rules applicable to the treatment of 
small-pox, and I pass now to the treatment of scarlet fever. 

Scarlatina, unlike variola, has no prophylactic treatment, for nearly all 
attempts to prevent this disease by inoculation have failed. 1 

Impotent to combat the invasion of the disease by vaccination, some physi- 
cians have pretended to be able to prevent it by prophylactic medication, and 
taking as their basis this strange notion that since the ingestion of belladonna 
gives rise to a scarlatinous eruption, it must therefore cure scarlatina, and fol- 
lowing in the wake of Hahnemann, they have proclaimed belladonna as both 
curative and prophylatic. 2 To-day this question is absolutely settled, and all 
are agreed in regarding this pretension of the specificity of belladonna as 
illusory. 

Moreover, I regard scarlatina as the least contagious of the eruptive fevers 

1 Inoculation for scarlatina was attempted by Miguel, Mandl, Petit-Radel, and Most. 
Miguel made use of blood taken from the scarlatinous patches, and he saw produced around 
the punctures a red circle, which disappeared the seventh day. These subjects of inocula- 
tion are rebellious to scarlatina. Leroy, of Etiolles, witnessed the same results after inocu- 
lation with blood from a scarlet fever patient. Mandl has advised inoculation with the pro- 
duct of the miliary vesicles which accompany scarlatina. Darwin practiced inoculation with 
the liquids furnished by the ulcerations of the pharynx. As for Most, he proposes the inocu- 
lation of blood taken from swine affected with a sort of quinsy, accompanied by an erysipel- 
atous eruption, (a) 

2 Hahnemann was the first to prescribe belladonna in homoeopathic doses as a prophy- 
laxis in scarlatina. He based himself on this fact, that belladonna in large doses determines 
an eruption analogous to that of scarlet fever. This prophylactic action has been tested in 
Germany, England, and France, by numerous experimenters, as will be seen by consulting 
the bibliographical references given below. Notwithstanding the favorable results claimed 
by some of these authorities, everybody to-day is agreed in admitting this claim of Hahne- 
mann as to the protective power of belladonna in scarlet fever to be a delusion and an 
absurdity. (6) 



(a) Miguel d'Amboise, Bull, de 1' Acad, de Med., gth September, 1S34. Leroy d'Etiolles. A study of 
the preventive treatment of scarlatina by belladonna and by inoculation (Gaz. Hebd., 1878), Sanne. Art. Scar- 
latina in Diet. Encyclop. des Sc. Med. 

(&) Walburton-Begbie, British and foreign medico-chir. review, Janvier, 1855. — Berndt, Bestatigende 
Erfahrungen iiber die Schutzhraff der Belladonna, etc., Hufel. Journ., t. LI, st. II, p. 5, 1829.— Wolff, Die 
Schutzkraft der Belladonna geprtift in der letzten Scharlach-Epidemie, Horn. Arch., t. II, p. 490, 1822. — 
Puchelt, Bella, als Schutzm. gegen das Scharlach, geweirdigt heidelb., Klin. Ann., t. V, 242, 1885. — Hufland, 
Die Schutzkraft der Belladonna gegen das Scharl., neue, etc., Hufel. Journ., t. LXI, st. 5. p. 3, et Berlin, 1826. 
— Wildberg Einige wort iiber das Scharlach fieber und den gebraenh der Belladonna als Schutzmittel gegen 
dasselbe, Leipzig, 1826 — Maclure, Remarks on the extract of Belladonna given as Prophylactic against the 
contagion of Scarlet fever, in Loud. Med. Gaz., t. XXI, p. 363, 1838. — Morris, Experiments made to determine 
the protective power of Belladonna in Scarlatina, Amer. Journ., 2e serie, t. XXXIII, p. 334, 1857. — Shevenart, 
De l'emploi prophylactique de la belladone dans la scarlatine epidemiique, 1843. — Fe"ron, Note sur 1'emploi de 
la belladone dans la scarlatine, Journ. des conn. med. chir., 1859, t. II, p. 63. — Ibrelisle, Experiences faites 
avec la belladone employee comme preservatif de la scarlatine, Bull, de la soc. med. d'em., 1823, p. 204. 



470 ON THE TREATMENT OF ERUPTIVE FEVERS. 

(it is so, at any rate, in Paris), and the small number of scarlet fever patients 
that we receive into our wards have seldom or never given the disease to other 
patients. You know, moreover, how different is the mortality of scarlet fever 
according to the country in which it prevails; and while in England epidemics 
of this disease are characterized by their gravity, in France, and particularly in 
Paris, this affection is almost always isolated, and is dangerous principally by 
the complications which may arise during convalescence. I shall then be very 
brief concerning the therapeutic indications which the question of treatment 
suggests. 

In the period of invasion, which is generally very short, you may employ 
sudorific ptisans or teas, liquor ammoniac acetatis, and especially carbonate of 
ammonia, which has been vaunted by Peart, by Wilkenson, by Strahl, and by 
Ricken, of Brussels. 

During the period of eruption the indication is to diminish the dryness of 
the skin, and facilitate desquamation by inunctions made with fatty substances. 1 
Some, as West, employ lard, others bacon fat. Scoutetten recommends sweet 
oil. I am in the habit of using vaseline, which does not oxidize or become 
rancid. You will do well, then, at the period of desquamation, to practice fre- 
quent inunctions of vaseline over the whole body, both to hasten the fall of the 
epidermic scales, and to protect the skin from exterior agents. This state of 
the skin is, as you know, one of the sources of danger during convalescence, by 
reason of the renal complications which may arise; you ought then to insist 
upon the greatest precaution during the period of convalescence, and keep the 
patient for six weeks in his room, and generally one month in bed, and never 
allow him to go abroad till there shall have been complete renewal of the epi- 
dermis. You can aid this process of reparation by warm baths while the epi- 
dermis is scaling off. 

I shall not speak here of the pharyngeal complications of scarlet fever; 
you are familiar with the morbid determinations of this disease to the throat, 
whether it consist in a pultaceous angina or in a veritable diphtheria, according 
to Archambault's views, who unites scarlatina and diphtheria in the same de- 
scription; the same treatment is proper for both, and I need not here repeat 
what I told you when on the subject of diphtheritic sore throat. But there is 
another complication which ought to occupy us a few minutes. I refer to the 

1 West recommends during the eruption to anoint the whole surface of the body with 
lard. Eberth, in 1851, put in use another popular practice, which consisted in making 
inunctions at all periods of the disease with bacon fat. Scoutetten made use of oil, slightly 
warmed, and this was his manner of procedure: By means of a piece of flannel wet in this 
oil, all parts of the body were rubbed for a few minutes, without excepting the face and feet; 
then the frictions being terminated, the patient was put to bed and kept there for two hours, 
the next day he was given a bath, with temperature about 90°F., of one hour's duration; 
being taken from the bath, he was put to bed, and submitted to another rubbing with oil. 
This treatment is exclusively put in practice when the patient is about to leave his room, and 
in order to free the skin of the pellicles which cover it. (a) 



(a) West, On the Diseases of Children. London, 1880.— Scoutetten, On Measles and Scarlatina; mis- 
takes and misjudgments in the treatment of scarlet fever. Metz, 1868. 



ON THE TREATMENT OF ERUPTIVE FEVERS. 471 

nervous manifestations which accompany certain scarlatinous eruptions, and 
which are tributary to a treatment to which Trousseau has devoted one of the 
finest passages of his clinical lectures — I refer to the treatment by cold affu- 
sions. Recommended by Currie, 1 this method is become to-day classical, and 
in the practice of certain physicians, particularly the Germans, it is employed 
indiscriminately in all cases. Here, also, as in all the applications of the refri- 
gerant method, it is rather against the manifestations on the part of the nervous 
system, than the elevation of temperature, that these cold affusions can render 

1 Currie was the first to employ affusions and lotions of cold water in the treatment of 
scarlet fever. He treated his two sons, affected with malignant scarlet fever, and from 1800 
to 1804 more than 150 patients in the following manner: The patient was stripped naked and 
put into an empty bath tub, and four or five pailfuls of cold water were poured upon him. 
Since then this treatment has been very much employed in England as in France. Reed and 
Murray in 1803, Bruce in 1812, in England; Caron, of Annecy, and especially Trousseau, 
have very much vaunted affusions of cold water. Martin, of Nosen; Nasse, of Bielsfield; 
Besle, of Berlin, have also employed in Germany cold lotions. Moreover, since the appli- 
cation of the refrigerant method to the treatment of febrile affections, cold affusions, and 
especially cold baths, have been very much employed in the treatment of scarlet fever. 
Thus it is that Liebermeister affirms that he has employed cold baths with success in the 
treatment of scarlet fever, that Cohn has maintained that cold affusions constitute a prophy- 
lactic treatment of this affection, that Pelz has employed these baths to bring down the 
temperature, without, nevertheless, deriving the same advantages as in other febrile 
affections. 

Eddison applies cold water as a general method in the treatment of scarlet fever. The 
temperature of the bath ought to be about gST. at the commencement, and it should be 
gradually cooled down to 72°F. The duration of the bath should be according to circum- 
stances. He asks if it would not even be well to leave the patient several hours in the bath, 
if not all day. 

John Taylor has studied the action of the wet pack in scarlatina. It is, in his estima- 
tion, one of the best therapeutic means to arouse and promote the cutaneous elimination, in- 
terrupted in scarlatinous patients. The application of the wet pack should be renewed from 
two to four times during the twenty-four hours, each application lasting from half an hour 
to an hour. Taylor's method is as follows: A night gown, open in front, is taken and 
dipped in a basin of warm water, which may be pure, or medicated with a little mustard or 
tincture of pimento. This is well wrung out and wrapped around the patient, and the feet 
are enveloped in a towel, wrung out of warm water; then the patient is covered with three 
woolen blankets, and over the whole a thick coverlet is spread. 

Fraser employed, during an epidemic of scarlet fever, warm baths gradually cooled, or 
cold baths, guiding himself by the rectal temperature and the state of the nervous system. 
He gave one to six baths during the twenty-four hours to his patients. Under the influence 
of these baths he always observed an amelioration. (a) 



(a) Currie, Medical reports on the effects of water, cold and warm, as a remedy of fever and other dis- 
eases, Liverpool, 1798 et 1804; extr. dans Biblioth. britann., t. XVII et XXX, par Odier, idem, se edit., 2 vol., 
1814. — Reidet Murray, Scarlatine traite"e paries affusions froides, Med. and Phys. Journ.,t. XI, p. 27, 1803. — 
Bruce, Scarlatine traitee par les affusions froides, Med. chir. Trans., t. IX, p. 275, 1812.— Trousseau, Des affu- 
sions froides dans le traitement des accidents nerveux de la Scarlatine et du delire febrile dans cette maladie, 
Un. med., 1857, p. 411, Clin m6d. de l'Hotel-Dieu, se £dit., 1877. — Martin, de Nosen, Scarlatine traite'e par les 
affusions froides, Bull, des sc. mdd. de Ferussac, t. X, p. 349, 1814. — Liebermeister, Handbuck der Pathologie 
und Therapie des Fiebers, Leipzig, 1875.— Cohn, Hydrotherapie des Scarlach. Berlin, 1868. — Pilz, Mitthei- 
lungen iiber Behandlung des Scarlachfiebers mit, Baedern Jahrb. fur Kinderh.. t. Ill, p. 253. — Eddison, Note 
on the treatment of Scarlet fever by the external application of cold water with two cases, the Lancet, 4 et iS 
septembre, 1875, p. 340 et 414.— Taylor, the wet pack in Scarlatina, the Lancet, 14 november, 1875, p. 692.— 
Fraser, the Bath treatment in Scarlet fever, the Pract., vol. XXVII. no. 1, p. 34, 1881. 



472 ON THE TREATMENT OF ERUPTIVE FEVERS. 

service; and you will not need to put this mode of treatment in practice unless 
there shall supervene at the commencement of the period of eruption, ataxo- 
adynamic phenomena of great gravity. For my part I have never found, since 
I began the practice of medicine, cases of scarlet fever sufficiently grave and 
menacing to require such treatment. Scarlatinal dropsy does not offer any 
special therapeutic indication apart from that which I enunciated while on the 
subject of the treatment of albuminuria; and without dwelling longer on anti- 
septic medications 1 proposed for scarlet fever, I pass now to the treatment of 
measles. 

This very contagious, but little dangerous malady, (unless by the complica- 
tions which may arise), does not present any very special therapeutic indica- 
tions, and treatment should be directed rather to the morbid manifestations de- 
termined by the disease than to the disease itself. I shall then say very little 
on this subject, and you will have to apply here only the general hygienic and 
therapeutic measures proper to all the eruptive fevers, and which consist in 
warm sudorific ptisans, as well as the greatest care to prevent all exposure to 
chills, and in attention to the thoracic organs, so that you can interfere in time 
if any pulmonary complications manifest themselves. 

I have now finished the therapeutic indications which I desired to give you 
for the management of the eruptive fevers. 

These lectures complete the course on which I had determined; and in- 
complete as they are, they will furnish you data of a practical kind concerning 
the principal diseases which, in our country at least, you will be oftenest called 
upon to treat. 

1 Samson has proposed to treat scarlatina by antiseptics. He administers the sulpho- 
carbolate of soda in the dose of a gramme and a half. Brackenbridge has adopted this 
method of treatment, and has derived good results; he has even employed it as a prophylac- 
tic means, and, according to him, this medicament prevents infection. (a) 



(a) Brackenbridge, On the prevention and treatment of scarlatina. Med. Times and Gaz., 1875, 

p. 92. 



APPENDIX TO THE CHAPTER ON MEDICAL ELECTRICITY. 



BY DR. C. L. DANA. 



Since writing the chapter upon Medical Electricity, good absolute galvanometers 
have become attainable. They constitute an extremely important addition to the arma- 
mentarium of the electro-therapeutist. The unit of measurement is the milleampere 
as suggested by De Watteville. The dose of galvanism, measured in these units, 
ranges from one to 40 or 50 milleamperes, a current of moderate strength being about 
ten milliamperes. Vertical galvanometers are probably the best. Hirschmann, of Berlin, 
John S. Barrett, and Waite & Bartlett, of this city, make trustworthy instruments. The 
price is from $15.00 to $25.00. 

Additional accuracy in recording and dosing electricity is gained by indicating by 
formula the frequency, and length of time that the current is passed, and the size of the 
electrode. A prescription for the administration of galvanism, for example, can be written 
thus: 1$. Galvanic current, 10 m. a. -^ cm. daily; Polar; Labile; which means that a 
galvanic current of ten milleamperes' strength is to be given daily for five minutes with 
an electrode 15 centimeters square, by the polar method, the active pole being rubbed 
over the affected part (labile). 
New York, June, 1885. 



INDEX. 



PAGE. 

A. 

Acid, Arsenious: 

in Anaemia 238 

in Chorea 137 

in Chronic Deforming Rheumatism, 265 

in Diabetes 307 

in Intermittent Fever 442 

in Syphilis 324 

in the Treatment of Neuralgia 71 

Acid, Benzoic and Benzoates: 

in Gout 282 

Acid, Carbazotic: 

in Intermittent Fever 441 

Acid, Lactic: 

in Diabetes 304 

Acid, Phenic (Carbolic) : 

in Diabetes 303 

in Fever 361 

in Small-pox 465 

in Typhoid Fever 395 

Acid, Salicylic, History 252 

in Diabetes 303 

in Fever 361 

in Intermittent Fever 443 

in Rheumatism 254 

in Typhoid Fever 392 

Aconite and Aconitia: 

in Fever 360, 389 

Forms and Doses 58 

in the Treatment of Neuralgia 57 

Actea (Cimicifuga Racemosa): 

in Acute Rheumatism 257 

Acupuncture: 

in Neuralgia 65 

Aerotherapy: 

in Anaemia 240 

in Diabetes 303 

Aesthesiogenous Substances: 

in Hysteria 96 

Affusions: 

Cold Affusions on the Head 26 

in Tuberculous Meningitis 148 

in Typhoid Fever 385 

Albuminate of Iron 223 



PAGE. 

Alcohol: 

its Action 401 

Action on the Nervous System 14 

in Typhoid Fever 400 

Alimentation: 

Almond Bread 299 

of Anaemic Patients 240 

of Apoplectics 163 

Bran Bread 299 

as a Cause of Typhoid Fever 370 

in Diabetes 296 

Drinks in Diabetes 301 

in Epilepsy 135 

Fruits in Diabetes 300 

Gluten Bread 299 

in Gout 283 

in Hysteria 88 

in Intermittent Fever 451 

in the Prophylaxis of Tubercular 

Meningitis 147 

Regime of Bouchardat 298 

Regime of Cantani 297 

Regime of Seegen 302 

in Typhoid Fever 273 

Alkalies: 

in Acute Rheumatism 249 

in Diabetes 306 

in Gout 283 

Alkaloids: 

of Cinchona 422 

Amaurosis: 

in Hysteria 96 

Ammoniac Acetates: 

in Scarlet Fever 470 

in Small-pox 463 

Anemia: 

Adjuvant Medications 238 

Alteration of the Blood in 226, 227 

Arsenic 238 

Cerebral 158 

Different Kinds of 223, 224 

Hydrotherapy 239 

Hygienic Treatment of 240 

Iron 234 

Manganese 238 



476 



INDEX. 






PAGE. 

Anemia (Continued.) 

Pernicious 242 

Pharmaceutical Treatment 231 

Transfusion in 243 

Treatment of 230 

Treatment of Apoplexy by 162 

Aneurisms. 

Miliary. ... 157 

Aniline: 

in Chorea 132 

Anorexia: 

in the Convalescence of Typhoid 

Fever 374 

Antagonism of Atropia and Jaborandi . . r8 

Antifermentative Medicaments: 

in Diabetes 303 

in Dothinenteritis , . 395 

in Fever 361 

Antimonials: 

in Chorea 137 

in Gout 278 

Antiparasitic Injections : 

in Gonorrhoea 336 

Antipyrine, a New Antipyretic 409 

Uses and Modes of Giving 410, 411 

Antithermic Medication: 356, 363 

Apoplexy 154 

by Anaemia 158 

Apoplectic Constitution 163 

by Congestion 158 

Definition 155 

by Haemorrhage 161 

Pathogeny 155 

Treatment of 160-163 

Apparatus, Electrical 36 

Description of American Batteries, 42, 49 

Appendix to Chapter on Medical Elec- 
tricity 473 

Aquapuncture 66 

Arduin: Dr. Leon, on Antipyrine 409 

Argent, Nitrate of: 

in Myelitis 175 

in Syphilis 321 

Arnica: 

in Hemiplegia 161 

Arthritism 264 

assafoetida: 

in Hysteria 89 

Ataxia, Locomotor 182 

Douleurs Fulgurantes 183 

Hydrotherapy in 185 



PAGE. 

Ataxia, Locomotor (Continued.) 

its Incurability 183 

Their Treatment 185 

Treatment of. 184 

Atmosphere: 

Influence of in Intermittent Fever. . 414 

Atrophy: 

Muscular Progressive 187 

Atropine: 

Action of 19 

Antagonism of Jaborandi and Atro- 
pine 18 

Subcutaneous Injections of in Neu- 
ralgia 54 

Author's Preface Ill 

B. 

Balls of Mars 234 

Balneotherapy : 

in Hysteria 92 

Barks, of Cinchona: 

Kinds of . . . 421 

Barreswil's Liquor: 

in Diabetes 292 

Baths: 

in Arthritic Neuralgias 71 

Baths in Fevers 356 

Cold Baths in Cerebral Rheumatism, 260 

Cold Baths in Scarlet Fever 471 

Inconvenience of in Typhoid Fever, 382 

Prolonged Baths in Hysteria. . . .92, 93 

Vapor Baths in Rheumatism .... 258 

Warm Baths in Dothinenteritis. . . . 384 

Baths, Galvanic: 

in Chorea. 136 

Batteries, Electrical: 

and Their Uses 36 

Belladonna: 

in Epilepsy 113 

in Scarlet Fever 469 

Berberis Vulgaris: 

in Intermittent Fever 439 

Blisters: 

in Sciatica 65 

Blennorrh agi a : 

Chronic 33& 

Copaiba in 334 

in the Female 337 

Injections in 334 

Treatment of 333 

Treatment of 33 6 - 337 



INDEX. 



4?7 



PAGE. 

Blood: 

Alteration of Globules by Medica- 
ments 194 

Chromometer 198 

Composition of 192 

Corpuscles 193 

Haematimeter . 196 

Haemoglobin 194 

Importance of Enumeration of the 

Globules 197 

Importance of the Qualitative Ex- 
amination 198 

Intra-Peritoneal Injections of Blood 207 
Intravenous Injections of Medica- 
ments Condemned 199 

Intravenous Injections of Milk. . . . 207 

Intravenous Saline Injections 208 

Passage of Medicaments into the 

Blood 199 

Their Uses in Cholera and in the 
Collapse following Severe Hemor- 
rhage 208, 209 

from a Therapeutic Standpoint 191 

Transfusion 200 

of Animal Blood 201 

of Blood from Man to Man 203 

of Defibrinated Blood 202 

History of 200 

Indications and Contraindica- 
tions of 206 

Mediate and Immediate 200 

Mode of Operating 203 

Roussel's Method 204 

of Whole Blood 201 

Bloodletting 210 

Beneficial in Pulmonary Conges- 
tions Accompanying Heart Dis- 
ease 220 

Experimental Researches on 213 

History, Popularity and Decadence 

of 211, 212 

Indications for, General and Local. . 219 
Its Influence in Combating Phleg- 
masia 220 

Influence on Animal Heat 217 

Influence on the Circulation 215 

on the Nervous System 217 

Leeches 218 

Local, Influence of in Relieving the 

Pains of Pleurisy and Pneumonia, 221 

Local, Modes and Effects 218 

Modes of Bleeding 212 

Modifications which the Blood Un- 
dergoes from Bleeding 213 



PAGE. 

Boubee: 

Syrup of in Gout 277 

Bouchard at: 

His Alimentary Regime in Diabetes, 298 

Bourbon: 

Waters of in Diabetes 307 

Brand: 

Method of in Fevers 357 

Bromide of Potassium: 

Administration of 120 

of Ammonium 119 

Bromide of lodium 118 

of Calcium 119 

of Camphor.. ng 

in Chorea 134 

in Diabetes 307 

in Epilepsy 113 

History of the Bromide Medication, 114 

in Hysteria 90 

in Myelitis 175 

in Neuralgia 70 

Physiological Action of 117 

Results of the Bromide Medication, 122 

in Tuberculous Meningitis 149 

of Zinc 119 

Bromide of Ammonium: 

in Epilepsy 119 

Bromide of Camphor: 

in Epilepsy 119 

Bromide of Iodium: 

in Epilepsy 118 

Bromism 121 

C. 

Cachexia: 

the Paludal 450 

Caffeine: 

in Neuralgia 69 

Calmatives: 

in Tuberculous Meningitis 149 

Calomel: 

in Indurated Chancre 328 

in Tuberculous Meningitis 149 

in Typhoid Fever 398 

Calorimetry 349 

Camphor Bromide (see Bromide) 

Cancer: 

of the Spinal Cord 181 

Cantani: 

His Alimentary Regime in Diabe- 
tes 297 



478 



INDEX. 



PAGE. 

Carlsbad: 

Waters of in Gout 283 

in Diabetes 308 

Castor: 

in Hysteria 89 

Cauteries: 

in Epilepsy 111 

in Myelitis 172 

Cauterizations: 

of Chancres 328 

in Epilepsy in 

in Myelitis 172 

in Neuralgia 73 

Cedrine: 

in Intermittent Fever 439 

Centaury, European: 

in Intermittent Fever 439 

Chancre: 

Cauterization and Excision of 328 

Treatment of 328 

Treatment by Iodoform 328 

Chicken Cholera 457 

Chloral: 

Injections of in Blennorrhagic Vag- 
initis 336 

in Chorea 136 

in Convulsions 152 

in Neuralgia 55 

in Tubercular Meningitis 149 

Lotions of in the Treatment of Hard 

Chancre 328 

Modes of Administration 136 

Chloroform: 

Action on the Nervous System 14 

in Neuralgia 57 

Inhalations of in Chorea 131 

Subcutaneous Injections of 56 

Chlorosis (see Anaemia) 

Chloride of Gold: 

in Hysteria 97 

Chorea: 

Arsenic in , 138 

Bloodletting in 137 

the Bromides in 133 

Chloral in 136 

Chloroform in 136 

Curare in 132 

Different Choreas ; 130 

Electricity in 135 

Eserine in 133 

Ether Spray in 140, 136 



PAGE. 

Chorea (Continued.) 

Gymnastics in 138 

Hydrotherapy in 138 

Hyoscyamus 133 

Medicaments that Act on the Gen- 
eral Condition 137 

Medullary Medicaments in 133 

Morphine in 136 

Muscular Medicaments, Strychnine, 131 

Pathogeny of 129 

Picrotoxine in 134 

Spontaneous Curability of 128 

Sulphur Baths in . .. . 138 

Tartar Emetic in 137 

Treatment of 131 

Cinchona and Cinchona Bark, 

History of 420 

ClNCHONIDIA: 

in Intermittent Fever 425 

Cinchonia , 424 

Its Value. 425 

Circulation: 

Action of Bloodletting on the 215 

Action of Electricity on the 34 

Action of Hydrotherapy on the 21 

Action of Quinine on the 391 

Citrus Limonum (Lemon Juice): 

Antifebrile Properties of 374 

in Rheumatism 250 

Codeia: 

in Diabetes 305 

Colchicum 278 

in Gout 279 

Preparations of 280 

Colchicine and Colchiceine 280 

Coagulation of the Blood: 

Theories of 192 

Cold: 

Action on the Nervous System 22 

Affusions 26 

Applications in Meningitis 148 

Douches 24 

in Spinal Congestions , 185 

Modes of Application 23 

Physiological Action of 21 

Combustions, Organic: 

in Fever 350 

Compression: 

of the Ovaries in Hysteria 99 

Compressed Air : 

in Chlorosis 240 



INDEX. 



479 



PAGE. 

Congestion: 

Bloodletting in 161 

of the Spinal Cord 179 

Pulmonary Congestion in Typhoid 

Fever 382 

Treatment of Apoplexy by 162 

Constipation: 

After Ferruginous Medication 231 

Contagiousness of Typhoid Fever 366 

CONTINENCE: 

in Hysteria 86 

Contractions, in Hysteria: 

Treatment of 100 

Convulsions, in Infants: 

Treatment of 152 

Copabia: 

in Gonorrhoea 334 

Cow Pox vs. Horse Pox 457 

Croton Chloral: 

in Neuralgia 55 

Croton Tiglium, Frictions with: 

in Tuberculous Meningitis 147 

Cuprum: 

in Diabetes 307 

in Epilepsy 114 

Curare: 

in Chorea 132 

in Epilepsy 123 

Currents, Electric; (See Electricity) 

Currie: 

on Cold Affusions in Scarlet Fever. . 471 

Cyanides: 

in Acute Rheumatism 252 

Cyanide of Zinc: 

in Acute Articular Rheumatism 252 

in Arthritic Neuralgias 71 

D. 

Dana, Dr. C. L. : 

Medical Batteries 36 

Dax, Waters of: 

in Chronic Rheumatism 268 

Decubitus, Dorsal: 

A Cause of Myelitis 179 

Defecation, Troubles of: 

in Myelitis 181 

Delirium: 

in Typhoid Fever 405 

Treatment of 405 



page. 
Dermabioticon: 

in Neuralgia 66 

Dermic Method of Treating Syphilis. . 316 

Diabetes 285 

Alkalies in 305 

Alimentary Hygiene in 296 

Arsenic in 306 

Beverages in 301 

Bouchardat's Regime 298 

Bromide of Potassium in 306 

Cantani's Regime 297 

Codeia in 305 

Copper and Mercury in 306 

Electricity in 308 

Ergot of Rye in 305 

Exercise 303 

Foster's Analysis of Remedies in.. 304 

Glycerine in 301 

Glycosuric Urine in 290 

Grave 295 

History of 285 

Hydrotherapy in 308 

Hygiene of the Diabetic. 296 

Iodine and the Iodides in 305 

Lactic Acid in 304 

Local Treatment of 308 

Menus of Bouchardat 301 

of Fatty People 295 

of the Lean 295 

Opium in 305 

Pathogeny of 286 

Permanganate of Potash in 304 

Physiological Glycsemia 287 

Pharmaceutical Treatment of 303 

Prognosis of Diabetes 295 

Results of Treatment of 303 

Salicylic and Phenic Acids in 303 

Seegen's Regime 302 

Tests for Glucose 290-293 

Hiller's Process 291 

Bcettger's Process 291 

Trommer's Process 291 

Muller's Test 291 

Maumene's Test 291 

Fehling's Solution 292 

Dahomme's Method 292 

Thermal Treatment of 308 

Theories of 288 

the Mild Form of 295 

Valerian in 305 

Wines in 300 

Diaphoretics: 

in Acute Rheumatism 257 



480 



INDEX. 



PAGE. 

Diaphoretics (Continued.) 

in Gout 277 

Diathesis: 

Uric 270 

Digitalis: 

Donovan's Liquor in Syphilis 324 

in Fever 360 

Douches: 24 

Cold and Tempered in the Myelites, 

172, 185 

Duration of 25 

in Hysteria 93 

Scotch Douches 24 

Uses of in Various Neuralgias 70 

Various Forms of 24 

Douleurs Fulgurantes, 182 

Treatment of 185 

Duhomme: 

Method of Testing Diabetic Urine. . 293 
Table 294 

Dupuytren: 

Pills of in Syphilis 320 

E. 

Education in Hysteria 84 

In Chorea 139 

Electricity: 

Action on the Nervous System, on 

the Circulation, on the Nutrition, 34 

Chemical Phenomena of 32 

Directions how to Use Electricity. . 46 

Electro-Capillary of Electricity .... 33 

Electrical Batteries and their Uses, 36 

Faradic Electrical Batteries 41 

Franklinization 94 

in Chorea 135 

in Diabetes 308 

in Hysteria 94 

in Locomotor Ataxia 185 

in Medicine 28 

in Myelitis 173 

in Neuralgia 59 

in the Paralysis of Infants, and in 

Progressive Muscular Atrophy.. 

185, 186 

Intensity of the Current 31 

Muscular Phenomena of 32 

New Theory of 30 

Physical Phenomena of the Electric 

Current 32 

Static Electrical Batteries 38 



PAGE. 

Electricity (Continued.) 

Static and Dynamic Electrical Ap- 
paratuses 31 

Electro-Puncture: 

in Neuralgia 66 

Elongation of Nerves: 

Embolisms, Cerebral 155 

Empirical Medication in the Treat- 
ment of Neuralgia 67 

in Tuberculous Meningitis 149 

in Epilepsy 112 

Modus Operandi of Nerve-Stretching, 63 

Nerve-Stretching 76, 62 

Nerve - Stretching in Locomotor 

Ataxia 185 

Subcutaneous Nerve-Stretching 64 

Epilepsy: 108 

Bromide of Potassium 114 

(See Bromides). 

Cocculus Indicus in 123 

Curability and Incurability of 107 

Curare in 123 

Empirical Medication — Galium, Va- 
lerian, Belladonna, Indian Hemp, 
Nitrate of Silver, Oxide of Zinc, 
Ammonio-Sulphate of Copper, 112, 114 

Essential Epilepsy in 

Experimental Epilepsy no 

Hygienic Treatment 126 

Necroscopic Examination of Epilep- 
sy in 

Pathogeny and Etiology of 109 

Physiological Pathology of 112 

Therapeutics of Symptomatic Epi- 
lepsy 1 10 

Treatment of Essential Epilepsy ... 112 

Treatment of the Attack of 126 

Trepan in Epilepsy 110 

Ergotine: 

in Congestive Neuralgias 70 

in Myelitis 174 

in the Intestinal Haemorrhages of 

Typhoid Fever 406 

Eschars: 

Treatment by, in Myelitis 172 

Treatment of, in Typhoid Fevers . . 375 
Eserine: 

in the Treatment of Chorea 132 

its Dangers 133 

Ether: 

Inhalation of, in the Convulsions of 

Infants 152 

Spray of, in Chorea 136-140 



INDEX. 



481 



PAGE. 

Ethiop's Martial: 237 

Eucalyptus: 

in Intermittent Fever 440 

Exercise: 

in Diabetes 303 

in Hysteria . .' 84 

Expectancy: 

in Typhoid Fever 403 

F^cal (Theory): 

Disinfection of Faecal Matters in 
Typhoid Fever 372 

of Typhoid Fever 368 

Fehling: 

Solution of, as a Test for Glucose. . 292 

F. 

Ferrum: 229 

Artificial Chalybeate Waters 236 

Action on the Globules. 238 

Action of 227 

Absorption of 231 

Chalybeate Springs of the U. S. P. 236 

Defibrinated Blood 235 

Diminution of 232 

Dialyzed Iron 233 

Ferruginous Waters 236 

Preparations of 233 

Ferrous and Ferric Salts 233 

History of 229 

Hypophosphate, Carbonate, Sul- 
phate, etc 234 

Inconveniences of Ferruginous Med- 
ication 237 

Jeannel's Table 237 

Oxides of 233 

Potassio-Tartrate of Iron 234 

Peptonate of Iron 235 

Quevenne's Iron 233 

Vallet's and Blaud's Pills 234 

Fever: 

Antithermic Medications in 356 

Antipyrine as an Antithermic Medic- 
ament 409 

Bloodletting in 360 

Characteristics of 345 

Cold Baths and Warm Baths .. .357-358 
Digitalis, Ergot, Aconite, Veratrum, 
Antiseptic Medicaments,, Quinine 

361-362 

Humoral Theories 354 

Theories of 346 

Increase of Organic Combustions in, 349 
Kairin, Thallin, and Antipyrine in. . 361 



PAGE. 

Fever (Continued.) 

Medicaments Acting on the Circula- 
tion 360 

Physical Means of Abstracting Heat, 357 

Phenic Acid in 362 

Pyretogenous Substances 354 

Role of the Vaso- motors in 351 

Regulation of the Heat in 351 

Salicylic Acid in 361 

Thermogenetic Nerves and Centres 353 

Therapeutical Deductions 355 

from a Therapeutic Standpoint 343 

Fevers, Eruptive (See Small-pox, 

Measles, and Scarlet Fever) 452 

Fever, Intermittent: 412 

Atmospheric Influences 414 

Alkaloids of Cinchona 421 

Anti-periodic Action 419 

Absorption and Elimination of Qui- 
nine 428 

Arsenic 442 

Cinchona 415 

Cinchonia 424 

Cinchonidia 425 

Cedron 439 

Dosage of Quinine 448 

Eucalyptus 440 

its Forms 448 

Hypodermic Injections of Quinine . 435 

History 415 

Jaborandi 441 

Local Action of Quinine 427 

Lavements of Quinine 434 

Marsh Miasm 412 

Mode of Introduction of the Salts of 

Quinine 432 

Methods of Administration. 447 

Physiological Action 416 

Pernicious Fever 448 

Quinine. 422 

Quinidine 426 

Quinoleine 427 

Quinoidine 427 

Resorcin 443 

Roman, English, and French Meth- 
ods 447 

Salts of Quinine 429 

Succedanea of Quinine 439 

Salicylic Acid 443 

Spiders' Webs 444 

Treatment of the Paroxysm 447 

its Treatment 45° 

Telluric Miasm 412 



482 



INDEX. 



PAGE. 

Fever, Intermittent (Continued.) 

Vegetable Succedanea 439 

Valdivine 439 

Fever, Typhoid: 

Antiphlogistic Method 387 

Alcohol „ 400 

Advantages and Disadvantages, 380-382 

Antipyretic Medication 388 

Antithermic Medication 377 

Brandt's Method 377 

Calomel 399 

Contagiousness 366 

Cold Baths . 378 

Cold Lotions and Lavements 385 

Digitalis 388 

Etiology 365 

Exclusive Medications 402 

Expectancy 403 

Faecal Theories 369 

Hygienic Treatment of Typhoid 

Fever 372 

Kairin , 397 

Methods of Refrigeration 377 

Mercurials 399 

Purgatives 398 

Phenic Acid 395 

Quinine 389 

Results 379 

Resorcin '. . 397 

Refrigerant Apparatus 385 

Sewerage 369 

Salicylic Acid 392 

Theory ot Typhoid Contagion 367 

The Microbe of Typhoid Fever. . . . 367 

Theories of the Contagion 368 

Treatments of Typhoid Fever 377 

Tonic Medication 400 

Their Dangers 402 

Treatment of Indications 403 

Treatment of the Complications. . . . 405 
Warm Baths 384 

Fibrine: 

of the Blood 192 

Fowler's 

Solution in Chorea 138 

Fraxinus: 

in Acute Articular Rheumatism. . . . 257 
in Gout 280 

G. 

Galbanum: 

in Hysteria 89 

Gall: 

Pills of in Gout 278 



page. 

Galium: 

in Epilepsy 112 

Galvano-Caustic : 

in Neuralgia 66 

Gases: 

of the Blood 215, 193 

Gastric Troubles in Hysteria 105 

Gavage (Forced Feeding): 

in Convalescence of Typhoid Fever, 375 
in Hysteria 105 

Gelsemium: 

its History, Physiological Proper- 
ties, Uses, and Doses 58 

in Neuralgia 58 

Geological Conditions: 

as Causative in Typhoid Fever 630 

Gibert: 

Syrup of in Syphilis 320 

Globules: 

Action of Bleeding on 213 

Action of Iron on 229 

in Ansemia 224 

of the Blood 194 

Effects of Medicaments on 105 

Enumeration of 196 

Physiological Function of 195 

Qualitative Estimation of 198 

Glucose, in Urine (see Diabetes): 

Tests of 290 

Gluten: 

Bread of in Diabetes .....' 299 

Glyc^emia: 

Physiological 287 

Glycerine: 

in Diabetes 3 GI 

in Typhoid Fever 401 

Glycosuria: 

Physiological 287 

GOUGENHEIM: 

on Iodide of Potassium in Secondary 
Syphilis. 332 

Gonorrhoea (see Blennorrhagia): 

Gonorrhoceal Mixtures 333 

Gout: 

Action of Colchicum in 279 

Alkalies in 282 

Colchicum in 278 

Description of the Paroxysms of. . .. 273 

Divisions of 273 

European Ash in 280 

External Treatment of 281 



INDEX. 



483 



PAGE. 

Gout (Continued.) 

Guaracum in 277 

Hygiene of the Gouty Patient 2S3 

Jaborandi in 278 

J. Mortimer Granville on the Patho- 
geny and Treatment of Gout 284 

Medicaments Proposed for 277 

Mineral Waters in Gout, Carlsbad, 
Vichy, Wiesbad, Aix la Chapelle, 

Ems, Royal 283 

Pathogeny of 270, 271 

Purgatives in 278 

Quinine in .' 278 

Resume of General Treatment of. . 282 

Salicylate of Soda in 280 

Salts of Lithia in 282 

Treatment of the Fit of 275 

Grassit: 

Table of the Myelites 178 

Guarana (Paullinia): 

in the Treatment of Neuralgia...- 69 
Gurjun Oil: 

in Blennorrhagic Vaginitis 338 

Gymnastics: 

in Anaemia 240 

in Chorea 138 

in Diabetes 303 

Laisne's Method of Gymnastics in 

Chorea 139 

in the Prophylaxis of Tuberculous 

Meningitis 140 

in the Treatment of Anaemia 
Neuralgias 71 

H. 

HEMATIMETRY 196 

HEMATOBLASTS I94 

Hayem on 194 

Hematuria: 

from Quinine 437 

Hemoglobin 194 

Dosage of 197 

HAEMORRHAGES: 

Antithermic Effects of Haemor- 
rhages in Typhoid Fever 387 

Caused by Cold Baths in Typhoid 

Fever 382 

Treatment of by Perchloride of Iron 

and Ergot 406 

Hemorrhage, Cerebral (see Apoplexy). 
Hemorrhoids: 

in Apoplectic Patients 163 



PAGE. 

Hammond, Dr. W. A.: 

on the Treatment of Epilepsy by 

Bromide of Calcium 119 

on the Treatment of Chorea by 

Strychnia 132 

Hydrocephalas, Acute: (see Meningitis) 141 

Hydrotherapy : 20 

Affusions, and Packing in the Wet 

Sheet 26 

in Anaemia 239 

in Chorea 139 

in Diabetes 308 

Douches 24 

in Hysteria 93, 101 

Immersions 26 

Modes of Application 23 

in Myelitis 172, 181 

in Neuralgia 61, 70 

in Tuberculous Meningitis 148 

Hygiene: 

in Acute Rheumatism 262 

in Apoplexy 163 

in Chronic Rheumatism 269 

in Diabetes 296 

in Epilepsy 124 

in Gout 283 

in Hysteria 84 

in Intermittent Fever 450 

its Part in Therapeutics 5 

in Typhoid Fever 372 

Hyoscyamine: 

in Chorea 133 

Hyperthermia 352 

Treatment of Typhoid Fever 377 

Hysteria 80 

^sthesiogenous Substances in 96 

Assafcetida 89 

Bromide of Potassium 90 

Castor 8§ 

Electricity in 94 

Galvanism in Gastric Hysteria 105 

Gastric Hysteria 105 

General Treatment of 84 

Hydrotherapy in 92 

Intractibleness of Hysteria 106 

Medicinal Treatment of 88 

Meglin's Pills in 90 

Metallotherapy in 97 

Treatment of the Anaesthesia 102 

Treatment of Contractures 100 

Treatment of the Fit 98 

Valerian 89 



484 



INDEX. 



PAGE. 
I. 

Immersions 26 

Immobilization: 

in Acute Rheumatism 256 

Infantile Atrophic Paralysis 185 

Inhalation: 

of Odorous Substances in Hysteria, 100 

Injections: 

of Chloroform 57 

in Gonorrhoea 334 

Hypodermic, in Neuralgia 54 

Intravenous Injections of Milk 207 

Intravenous Injections (see Trans- 
fusion), 
of Quinine in Intermittent Fever. . 433 

Inoculation: 

for Scarlet Fever 469 

Inunctions: 

in Scarlet Fever 470 

Iodide of Potassium: 

in Chronic Rheumatism 266 

in Diabetes 305 

in Myelitis 174 

in Syphilis 323 

in Treatment of Cerebral Haemor- 
rhage 161 

in Tuberculous Meningitis 149 

Iodide of Iron: 

Syrup and Pills 233 

Iodine, Tincture of: 

in Acute Rheumatism 256 

in Chronic Rheumatism 266 

in Diabetes 305 

Donovan's Solution of Iodine and 

Mercury 324 

and the Iodides in Syphilis 323 

Iodized Cotton 256 

Method of Bernard (vascent iodine), 256 

Method of Bouvier 256 

in Plantar Neuralgia 72 

in Small-pox 467 

Tincture of, in Soft Chancres 328 

in Typhoid Fever 398 

Iodoform: 

in Chancre 328 

Means of Deodorizing 329 

Prescriptions Containing Iodoform, 329 

Iron, (see Ferrum). 

Jaborandi: 

Antagonism between and Atropine, 18 



PAGE. 

Jaborandi (Continued.) 

in Intermittent Fever 441 

in Rheumatism 257 

in Syphilis 322 

Jenner and his Discoveries 454 

K. 

Kairin: 

a New Antithermic in Fevers 361 • 

Keys: 

Directions How to Use Injections 

* in Gonorrhoea 336 

Krause's: 

Test for Diabetes 291 

L. 

Lartigue: 

Pill of in Gout 280 

Lasegue: 

Affirmation of Respecting Marriage 

on the Part of Epileptics 125 

on the Use of Iodine in Chronic 

Rheumatism 266 

Lavements: 

of Carbolic Water in Typhoid Fever, 395 
of Cold Water in Typhoid Fever. .. 386 

Laville: 

Liquor of in gout 280 

Leeches (See Bloodletting) 218 

Legumes: 

in Diabetes 300 

Liniments: 

in Rheumatism 248 

Lotions of Cold Water: 

in Fever 358 

in Small-pox 466 

in Typhoid Fever 404 

Luchon, Waters of: 

in Syphilis 333 

M. 

Manganese: 

in Anaemia 238 

Marriage: 

in Epilepsy. 125 

in Hysteria 87 

in Syphilitic Patients. 325 

Masks, Abortive: 

in Small-pox 459 



INDEX. 



485 



PAGE. 

Massage: 

in Chronic Rheumatism 267 

in Diabetes 303 

in Hemiplegia Consecutive to Apo- 
plexy. 161 

in Neuralgia 67 

Maumene's Test: 

for Saccharine Urine 291 

Measles: 

Treatment of 472 

Meningitis: 

Bloodletting in 148 

Bromides in 149 

Burrouse's Formula for Iodide of 

Potassium in Tuberculous in. . . . 149 

Calomel in 148 

Chloral in. 149 

Cold Applications in 148 

Croton Oil in 147 

its Curability 143 

Diagnosis of Tuberculous in 151 

General Treatment of 147 

Hygienic Treatment of 146 

Influence of Heredity 146 

Internal Treatment of 148 

Iodide of Potassium in, 149 

March of Tuberculous 143 

Moxa in 147 

Pathological Anatomy of 144 

Prophylactic Treatment of 146 

Quinine in . . ." 148 

Relationship of Chronic, to Mental 

Disturbances 152 

Revulsion 147 

Symptoms of 145 

Tartar Emetic Ointment 147 

Tuberculous 143 

Varieties of 142 

Walnut Leaves in 149 

Meningo-myelitis 180 

Mercury 311 

Absorption of 313 

Anti-syphilitic Action of 315 

by the Kidneys 314 

by the Liver 314 

by the Milk 314 

by the Sweat 314 

by the Saliva 314 

by the Skin 316 

Directions for Giving, in Syphilis. . 321 

English Anti- venereal Drops 320 

Forms of, for Internal Use 319 



PAGE. 

Mercury (Continued.) 

Gibert's Pills and Syrup 320 

Hypodermic Method of Administer- 
ing 317 

History of 311 

in Diabetes 307 

in Gout 278 

its Elimination 314 

Liquor of, Van Sweeten's 319 

Mercurial Baths 316 

Mercurial Inhalations 319 

Mercurial Salivation 315 

Mercurial Peptones 317 

Mode of Introduction of 316 

Neapolitan Hose 316 

Ointments of 316 

Records' Pills 320 

Sedillots' Pills 320 

Sublimate Injections 317 

Metallo-therapy : 

in Hysteria 96 

Migraine: 

its Pathogeny and Treatment. . .78, 79 

Mineral Springs of the U. S.: 

in Anaemia 235 

in Chronic Rheumatism 267 

Morphine: 

in Hysteria 92 

in the Treatment of Neuralgias 54 

its Action 15 

its Inconveniences in Hysteria 92 

Subcutaneous Injections of, in Neu- 
ralgias 54 

Subcutaneous Injections of, with 

Atropine 54 

MoxA: 

in Tuberculous Meningitis 147 

in Chronic Myelitis 172 

Musk: 

in Hysteria 89 

Mullen: 

Test for Diabetic Urine 291 

Myelitis 166 

Acute or Parenchymatous 169 

Bloodletting in Affections of the 

Cord 180 

Bromides 174 

by Electrical Points 172 

Cold as a Therapeutic Measure. ... 172 

Ergot 174 

Electricity 173 

General Treatment 170 



486 



INDEX. 



PAGE. 

Myelitis (Continued.) 

Grasset's Table of the My elites. ... 178 
Infantile Atrophic Paralysis and its 

Treatment 182 

Interstitial 169 

Iodide of Potassium 174 

Locomotor Ataxia and its Treat- 
ment 182 

Nitrate of Silver in the Chronic 

Forms of 175 

Pathogenic Treatment 170 

Phosphorus Medication ... 176 

Preventive Treatment 171 

Progressive Muscular Atrophy 187 

Strychnia 1 74 

Treatment by Revulsion 171 

Treatment of Congestion of the 

Cord 179 

Treatment of the Sequalae of 181 

Types of 168 

Warm Douches 173 

N. 

Narcotics: 

in Diabetes 305 

Nephrotomy and Nephrectomy: 

in Ilio-lumbar Neuralgias 74 

Nervous System: 

Action of Medicaments on 12 

Action of Quinine on the 419 

Chemical Composition of n 

Influence of on the Capillary Circu- 
lation 15 

Influence of Bloodletting on the. . . 216 

its Constituents 10 

Neuralgias 50 

Aconite and Aconitia 57 

Acupuncture 65 

Ammonio-Sulphate of Copper 69 

Anodyne Medication 53 

Arsenic in Neuralgias 71 

Blisters 65 

Caffeine 69 

Cautery 65 

Chloral and Croton Chloral 54 

Chloroform 56 

Definition of 51 

Diathetic Neuralgias and their 

Treatment 71 

Electricity 59 

Electropuncture 66 

Empirical Medication 67 



page. 
Neuralgias (Continued.) 

Ergot in Congestive Neuralgias. .. . 70 

Facial Neuralgia 76 

Gelsemium and Gelsemine 58 

Hydrotherapy 61 

Hygienic and Tonic Medication of 

Chlorotic Neuralgias 71 

Hypodermic Injections of Caustic 

Solutions 66 

Ilio-Lumbar Neuralgias 73 

Influence of the Blood on 52 

Influence of the Nervous System on, 52 

Intercostal Neuralgias 74 

Malarial Neuralgias, Quinine. ..... 71 

Massage 67 

Migraine 77 

Odontalgia 75 

of the Fifth Nerve 75 

Pathogenic Medication 69 

Pathogeny of 52 

Paullinia 69 

Peripheral Causes 53 

Phosphide of Zinc 68 

Phosphorus 68 

Plantar Neuralgia 72 

Revulsion in 73 

Revulsive Medication 64 

Sciatica 72 

Subcutaneous Injections 54 

Surgical Measures, Neurotomy, 
Neurectomy, and Nerve Stretch- 
ing 61-64 

Symptomic Treatment 53 

Treatment of 78 

Turpentine 67 

Visceralgias 73 

Neuritis 70 

its Treatment 7° 

Nerve Stretching 64 

Neurotomy and Neurectomy 61 

Nitrate of Silver: 

in Epilepsy 113 

in Hysteria 97 

in Myelitis i?5 

Nitrate of Sodium: 

in Epilepsy 123 

Nitrite of Amyl: 

in Epilepsy 123 

Nutrition: 

Action of Bloodletting on 217 

Action of Electricity on 34 

Action of Hydrotherapy on 23 



INDEX. 



487 



Obesity: 

in Apoplexy 162 

Odontalgia 75 

Opthalmoscope: 

in the Diagnosis of Tubercular 
Meningitis 143 

Opium: 

in Chorea 131 

in Diabetes 305 

in Hysteria 91 

in the Treatment of Neuralgias. ... 54 
in Tuberculous Meningitis 149 

Ovaries: 

Compression of in Hysteria 99 

Overcrowding: 

in Typhoid Fever 368 

Oxide of Iron 233 

Oxide of Zinc: 

in Epilepsy 114 

in Hysteria 97 

Oxygen, 

Inhalations of in Diabetes 303 

Oxyhemoglobin 194, 225 

P. 

Paludal Affections (see Intermittent 

Fever). 
Paralysis, Atrophic: 

of Adults (Progressive Muscular 

Atrophy) 187 

of Infancy 185 

Pathogenic Medication: 

of Myelitis 1 70 

of Neuralgia 69 

Paullinia (see Guarana) 69 

Formula of Geo. M. Beard, con- 
taining Paullinia 69 

Peptone: 

Mercurio-Ammoniacal in Syphilis.. 318 
Peptonate of Iron: 

Jaillet's Formula 232 

Perchloride of Iron: 

in Anaemia 234 

in the Intestinal Haemorrhages of 

Typhoid Fever 406 

Note on Tincture of 234 

Perforations: 

Intermittent Fever 448 

Intestinal 406 



PAGE. 

Phenic Medication (Carbolic Acid): 

in Diabetes 303 

in Fever 363 

in Typhoid Fever 395 

Phosphorus: 

in Locomotor Ataxia 176 

in the Treatment of Neuralgia 68 

Mode of Action of in Myelitis 177 

Rules for the Administration of. . . . 177 

Phosphate of Zinc: 

in Myelitis 176 

in Neuralgia 68 

Picrate of Ammonia: 

in Intermittent Fever 441 

Picrotoxine: 

in Chorea 134 

in the Treatment of Epilepsy 123 

its Results 124 

Pills: 

Anticathartic 278 

Antisyphilitic of the French Codex, 320 

Blaud's and Vallet's Iron Pills 234 

Ferri Co 233 

Ferruginous of the Belgian Ph 234 

form of Giving Quinine 432 

Formulae for Quinine Pills 433 

Gross' Neuralgic Pill 71 

Meglin's, in Hysteria 90 

of Biniodide of Mercury (Gibert's). . 320 

of Dupuytren 320 

of Record for Syphilis 320 

Pilocarpine: 

in Intermittent Fever 441 

in Syphilis 322 

Plasma: 

of the Blood 192 

Plambieres: 

Waters of, in Chronic Rheumatism, 268 

Pomades: 

in Rheumatism 248 

in Vaginal Blenorrhagia 337 

Portland: 

Remedy of Duke of, in Gout 282 

Potatoes: 

in Diabetes 300 

Potassa: 

Salts of, in Rheumatism 249 

Potassium Iodide: (see Iodide of Potas- 
sium). 

Potassium Bromide: (see Bromide of 
Potassium). 



488 



INDEX. 



PAGE. 

Pott's Disease: 

in Myelitis 181 

Priessnitz (see Hydrotherapy). 

Prophylamin : 

in Rheumatism 251 

Proropalgia: 

Treatment of 76 

Pulse: 

Action of Bleeding on 215 

Temperature on 344 

Purgatives: 

in Apoplexy 163 

in Gout 277 

in Typhoid Fever 399 

Pyretogenous Substances 354 

Q. 

Querin: 

Remedy of in Gout 278 

Quinidine 426 

Quinine: 

Associated with Aconite in Neural- 
gia 71 

Dosage of Quinine 448 

Doses of, and Dangers of, in Ty- 
phoid Fever 392 

Hypodermic Injections of Bromhy- 

drate of Quinine 436 

Influence of Quinine in Producing 

Hsematuria 438 

in Articular Rheumatism 247 

in Fever 361 

in Intermittent Fever 416 

in Neuralgias of the Intermittent 

Kind 71 

in Tuberculous Meningitis 149 

in Typhoid Fever 389 

Mode of Action in Malarial Fever,4 1 7-420 
Mode of Elimination of Quinine . . . 428 

Modes of Introducing Quinine 432 

Pills of Quinine 434 

Pulverulent Form . . . . 433 

Quinine as aCongestioning Medica- 
ment of the Uterus 438 

Quinine Intoxication 437 

Quinine Lavements 434 

Roman, English and French Meth- 
ods of Giving Quinine in Inter- 
mittent Fevers 447 

Salts of Quinine 429 

Solutions of Quinine 433 



PAGE. 

Quinine (Continued.) 

Superiority of Quinine over Other 
Medicaments in Intermittent Fe- 
ver 439 

Quinoidine: 427 

Quinoleine: 427 

Refrigerants: 

Dangers of the Cold Bath in Ty- 
phoid Fever 382 

Effects of the Method 359 

Formula of Brandt 377 

History of the Refrigerant Method, 357 
Inconveniences of the Refrigerant 

in Typhoid Fever 379 

in Fever 356 

Modes of Application 358 

Refrigerants in Typhoid Fever .... 378 

Regimen, Alimentary (see Alimentation). 67 

Remedy, Indian, in Neuralgia 

of the Policeman of Lyons, in Neu- 
ralgia 65 

Resorcin: 

in Fever 361 

in Gonorrhoea (Dellenbaugh's In- 
jection) 335 

in Intermittent Fever 443 

in Typhoid Fever 397 

Respiration: 

Action of Bleeding on 216 

Revulsion: 

in Articular Rheumatism 247 

in Epilepsy in 

in Gonorrhceal Rheumatism 255 

in Muscular Rheumatism 255 

in Myelitis 172, 180 

in Neuralgia 65 

in Tuberculous Meningitis 147 

Rheumatism: 

Acid Treatment of 250 

Acute 245 

Ammoniacal Salts in 250 

Antifebrile Medication in ... 247 

Antiphlogistic Medication in 246 

Arsenic 265 

Care of Habitations 269 

Cardiac Complications 259 

Cerebral Complications 260 

Chronic Rheumatism 263 

Diaphoretics in Rheumatism 257 

Electricity in Deforming Rheuma- 
tism 267 

Gonorrhceal Rheumatism 255 



INDEX. 



489 



PAGE. 

Rheumatism (Continued.) 

Iodine 266 

Kinds of 263 

Liniments 248 

Local Treatment of 247 

Mineral Waters 268 

Natural Evolution of 246 

Propylamine in 251 

Revulsions and Anodynes 249 

Rules for the Salicylic Medication. . 253 

Salicylate of Soda 266 

Salicin in 252 

Salicylic Acid 253 

Salicylate of Soda 253 

Salts of Potash and Soda 249 

Specific Treatment of 249 

Summary of Treatment of Rheuma- 
tism 259 

Theories of 245 

Tonic Treatment 268 

Treatment of 265 

Rubeola (see Measles). 

S. 

Salicylate of Soda: 

in Chronic Rheumatism 266 

in Gout 280 

its Results in Acute Rheumatism.. 255 

in Rheumatism 253 

Rules for its Administration 254 

in Small-pox 467 

in Typhoid Fever 393 

Saffron of Mars: 

Aperient 233 

Salicylic Acid (see Acid Salicylic) 

Salicylic of Bismuth: 

in Typhoid Fever. . 394 

Salivation: 

Mercurial 314 

Scarlatina 470 

Prophylactic Treatment of 471 

Treatment of the Period of Erup- 
tion 470 

Sciatica 72 

Double Sciaticas 73 

Revulsion in 73 

Treatment of 72 

Treatment of by Blisters 65 

Secale Cornute (Ergot of Rye) 

Action of 16 

in Cerebral Haemorrhage 161 

in Diabetes 304 



page. 

Secale Cornute (Continued.) 

in Myelitis 174 

in Typhoid Fever 401 

Sepsine 354 

Serum: 

Intravenous Injections of 202 

Seton: 

in Diabetes 308 

in Epilepsy in 

in Myelitis 180 

Soda: 

Salts of in Acute Rheumatism 249 

Small-pox (see Variola) 

Statistics: 

Value of in Therapeutics 380 

Strychnia: 

in Chorea 131 

in Hemiplegia 162 

in Myelitis 174 

Sucrocarbonate of Iron 234 

Sudorifics (see Diaphoretics) 

Sulphate of Carbon: 

in the Treatment of Indurated 
Chancre 329 

Sulphate of Copper: 

in Epilepsy 114 

in Neuralgias 69 

Sulphate of Zinc: 

in Chorea 134 

in Epilepsy 114 

Sulphur: 

as an External Application in Neu- 
ralgia 65 

in Syphilis 324 

Suppositories: 

Vaginal 337 

Sydenham: 

Electuary ot in Gout 280 

Symptomatic Me ,ication of Neuralgia. . 53 

Syphilis: 

Absorption and Elimination of Mer- 
cury 313, 314 

Adjuvant Medications. 321 

Antisyphilitic Action of Mercury.. 315 

Arsenic in 324 

Cauterizations, Lotions 327, 328 

Choice of a Mercurial 321 

Curability of 326 

Dermic Method 316 

Diagnosis of the Primary Lesions. . 326 



490 



INDEX. 



PAGE. 

Syphilis (Continued.) 

Doses of Iodide of Potassium in.. 324 
Forms for Internal Administration 320 

History 310 

Hypodermic Method 317 

Iodides 323 

Iodoform 329 

Mercury, its History 312 

Methods of Treatment in, Fournier's 

and Martineau's Systems 325 

Modes of Introduction of Mercury 316 
Necessity of Mercurial Treatment in, 311 

Origin of 310 

Syphilitic Complications 332 

Time when the Specific Treatment 

should be Begun 326 

Treatment in Chancres, Indurated, 327 
Treatment of Gonorrhoea in the Fe- 
male 337, 338 

Treatment of Gonorrhoea in the 

Male 334, 335 

Treatment of the Secondary Stage, 

Van Swieten's Liquor 330 

Treatment of Soft Chancre 333 

Treatment of the Tertiary Period. . 331 

T. 

Tartrate of Antimony: 

in Chorea 137 

Tic Douleureux, of the Face: 

Treatment of 76 

Tonic Medication: 

of Typhoid Fever 400 

Transfusion: 

Apparatuses 203 

with the Blood of Animals 201 

with Defibrinated Blood 202 

H istory 200 

Indications and Contra-indications 

for 206 

Operative Procedure 205 

Roussets' Transfusion Apparatus. . 204 
with Whole Blood 202 

Trepan: 

in the Treatment of Epilepsy no 

TRIMETH YLAMIN : 

in the Treatment of Acute Rheuma- 
tism 251 

Turpentine: 

in the Treatment of Neuralgia 67 

U. 
Urea 271 

Augmented in Fever 346 



page. 

Uremia 277 

Uric Diathesis. 270 

Relationship of, to Gout. 271 

Urine: 

Glycosuric 287 

Physiological Glycosuria 287 

Test for Sugar in the 292 

Theories as to the Origin of Patho- 
logical Glycosuria 288 

V 

Vaccination 454 

with Animal Virus 460 

History 454 

with Humanized Virus 461 

Modes of Performing 459 

Preservation of Vaccine 462 

Protective Value of 455 

Vaccinal Syphilis 4^0 

Vaccinal Tuberculosis 461 

Valdivine: 

in Intermittent Fever 439 

Valeria: 

in Epilepsy 113 

in Hysteria 90 

Van Swieten's Liquor: 

in Syphilis 319 

Variola 452 

Abortive Mask 465 

Cardiac Complications 468 

Disinfectant Lotions and Baths. . . . 466 

Ether Opium Medication 468 

Period of Desiccation 469 

Period of Invasion 463 

Period of Suppuration 465 

The Rachialgia and the Constipa- 
tion 463 

Treatment of 454-469 

Treatment of Complications 469 

Treatment of the Eruption 464 

Vacuolization 453 

Vaso-Motors: 

Action of Medicaments on the 15 

Influence of, on Calorification 353 

Vaso-Constrictor and Vaso-Dilator 

Medicaments 15 

Veratrum Viride : 

in Rheumatism 252 

Vesicatories: 

in Acute Rheumatism 256 

in Epilepsy in 



INDEX. 



491 



PAGE. 

Vesicatories (Continued.) 

in Neuralgias 53-65 

in Tuberculous Meningitis 147 

Vichy, Water of: 

in Diabetes 308 

in Gout 283 

Vic d'Azyr and Gall: 

Pills of in Gout 278 

Vinegar: 

Antiseptic 466 

VlSCERALGIAS: 

Treatment of 73 

Vomiting: 

Treatment of in Hysterical Females, 105 



W. 



Water: 

as a Remedial Agent (see Hydro- 
therapeutics). 

Wet Wrappings: 

in Scarlet Fever 471 

in Typhoid Fever 386 



Xylotherapy: 

in Hysteria 97 



. •yaiaamv jo smvis aaiiua 



■ss3a9Noo jo Aavaan 



